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The Burdens of Disease

The Burdens of
Epidemics and Human
Response in Western
Revised Edition

J. N. Hays

Rutgers University Press

New Brunswick, New Jersey
and London
Library of Congress Cataloging-in-Publication Data

Hays, J. N., 1938–

The burdens of disease : epidemics and human response in western
history / J.N. Hays. — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–8135–4612–4 (hardcover : alk. paper) —
ISBN 978–0–8135–4613–1 (pbk. : alk. paper)
1. Epidemics—History. I. Title.
[DNLM: 1. Disease Outbreaks—history—Americas. 2. Disease
Outbreaks—history—Europe. 3. Western World—history—Americas.
4. Western World—history—Europe. WA 11 GA1 H425b 2009]
RA649.H29 2009

A British Cataloging-in-Publication record for this book is available from the

British Library.

Copyright © 1998, 2009 by J. N. Hays

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List of Tables ix
Acknowledgments xi

Introduction 1
One The Western Inheritance: Greek and
Roman Ideas about Disease 9
Two Medieval Diseases and Responses 19
Three The Great Plague Pandemic 37
Four New Diseases and Transatlantic Exchanges 62
Five Continuity and Change: Magic, Religion,
Medicine, and Science, 500–1700 77
Six Disease and the Enlightenment 105
Seven Cholera and Sanitation 135
Eight Tuberculosis and Poverty 155
Nine Disease, Medicine, and Western Imperialism 179
Ten The Scientific View of Disease and the
Triumph of Professional Medicine 214
Eleven The Apparent End of Epidemics 243
Twelve Disease and Power 283

Notes 315
Suggestions for Further Reading 341
Index 357


7.1 City Populations: 1800, 1850, 1880 142

7.2 Average Ages of Death in City and Country, England, 1842 145
8.1 Deaths at an Early Age, 1776–1849 159
8.2 Percentage Rates of Urban Growth, 1800–1910 165
11.1 Death Rates in Selected Countries: Nineteenth Century and c. 1914 247
11.2 Deaths per 100,000 Population, 1871–1960: Diarrheal and Digestive
Diseases 257
11.3 Deaths per 100,000 Population, 1871–1960: Pneumonia, Bronchitis,
Influenza 257
11.4 Deaths per 100,000 Population, 1871–1960: All Infections 258
11.5 Deaths per 100,000 Population, 1871–1960: Diseases of the Circulatory
System 258
11.6 Deaths per 100,000 Population, 1871–1960: Malignant Neoplasms 259


In this revised edition of The Burdens of Disease I remain deeply indebted to those
historians and other scholars whose works continue to inform my ideas about
the history of epidemic disease. Since the first edition was published in 1998 that
scholarship has grown steadily richer, deeper, and more enlightening. The
updated “Suggestions for Further Reading” reflect some of that wealth, and
I hope that the readers of this book will make use of them and so derive the same
pleasures from them that I have enjoyed.
Early in my historical training three distinguished scholars at the University
of Chicago inspired me. Allen Debus introduced me to the history of science,
still my bridge between C. P. Snow’s two cultures. William McNeill’s breadth of
vision and imagination provided excitement and stimulus, even before his semi-
nal Plagues and Peoples helped create interest in the history of disease. John Clive
(later of Harvard University, and now deceased) constantly reminded me that
history is a humanistic pursuit.
My students at Loyola University Chicago, including undergraduate, gradu-
ate, and medical students, persistently asked unanswerable and hence important
questions. Loyola’s Department of History has remained a genial and stimulat-
ing group of colleagues and friends; I could not have found a more congenial
environment for my career. I must also thank Loyola University for the grants of
two leaves of absence that facilitated the original conception and completion
of the book.
Since the appearance of the first edition, I have gained both ideas and encour-
agement from a variety of readers and reviewers. And as have so many scholars,
I have shamelessly exploited the professionalism and resources found in
libraries, especially (in my case) those of the University of Chicago, Loyola

xii Acknowledgments

University Chicago, and the Wellcome Centre for the History of Medicine at
University College London. At Rutgers University Press, senior editor Doreen
Valentine has rendered invaluable professional counsel, and the whole Rutgers
Press staff has made the production process a pleasure.
And to my wife, Rosalind Hays, I still owe more than I can properly express,
and certainly more than I can ever repay. She shares whatever merits this book
may possess. The flaws and errors that remain are mine, all mine.
The Burdens of Disease

D isease and illness have obvious importance to human life. In recent

years, popular awareness of them has sharpened with concerns about a new
worldwide pandemic, perh aps of some form of Asian bird flu spreading to
humans. More than ever some understanding of the workings of disease within
Western (and world) history should inform our responses to present and future
epidemic crises. This book, a second and revised version of the original, pres-
ents a view that emphasizes alike the individual reality of sickness and death, the
social responses to such physical illness, and the changing ways in which
Western societies have constructed the meaning of disease.
Disease is both a pathological reality and a social construction. Both material
evidence for it and convictions about it exist; concentration on one to the exclu-
sion of the other (as some earlier historical writing has done) has sometimes
made a neater story, but an incomplete one. Especially during the period from
the late nineteenth century through the mid-twentieth, disease seemed an objec-
tive biological phenomenon, and those who combated it were scientific physi-
cians. A large literature in the history of medicine resulted, one that focused on
those figures from the past whose actions and thoughts most closely foretold the
model of modern Western biomedicine. That literature usually said little about the
effects of disease on social structures or on individual, everyday lives. More recently
two other conceptions of disease complicated this positivist picture. Many social
scientists and historians came to consider disease above all as a cultural con-
struct, rooted in mental habits and social relations rather than in objective bio-
logical conditions of pathology. Other writing saw disease as a force in its own
right, an implacable product of a biological world in which humans are
prey as well as predators. That view, associated with historians’ concern with the

2 The Burdens of Disease

long-term conception of time and with environment rather than events, shifted
attention from the medicine-centered approach to disease, but in doing so it may
have reduced human responses to insignificance.
The rich volume of scholarship in the last three decades on the history of
particular diseases and disease episodes has shown the connections between
diseases and social and political changes, the role of disease in the uncovering of
social tensions, and the interactions of disease and changes in medical practice.
It has explored the complex role of governments in the provision of health care,
and the even more complex factors of professionalization that lay behind mod-
ern scientific medicine. It has recovered both the variety and persistence of folk
traditions and other responses to disease outside the realm of official medicine.
This book aims to apply such approaches to the history of disease in Western
civilization as a whole, while also insisting on the importance of the biological
and pathological realities of disease and hence of the traditions of scientific
Disease has affected Western civilization in a number of ways in different
times and places. Some of its most obvious effects have been demographic: dis-
ease has led to periods of stagnant or falling human population, for example, in
Europe in the late fourteenth and early fifteenth centuries. In the last two cen-
turies human responses (especially in the West) to disease have themselves
affected demography, in ways still subject to historical argument. Disease has
had social effects, as in the sharpening of class lines between immigrants and
“natives” in nineteenth-century American cities. Its political effects have been
numerous, and sometimes dramatic: it played a crucial role in the overwhelming
of Native American polities by European invaders, and it has decided both bat-
tles and the fates of European dynasties. Disease has affected economies, both
by demographic pressure that has changed the supply and hence the price of
labor and by its effects on the productivity of a particular region or social group.
Disease’s intellectual and cultural effects have been far-reaching and profound; it
has channeled (or blocked) individual creativity, and it may on occasion have set
its stamp on the “optimism” or “pessimism” of an entire age.
In perhaps less obvious ways, civilization has also affected disease. Some civi-
lizations, by their very restlessness, have increased disease’s opportunities.
European incursions in the tropics have meant contact with yellow fever;
European contacts with Native Americans resulted in a complex interchange of
microorganisms and diseases; the networks of medieval trade, both by sea and
land, made the movement of plague easier, as did the steam transportation of the
nineteenth century. Many cultures and civilizations, including the Western, have
attempted to control disease or perhaps even eliminate it, although control and
elimination are different goals that have been adopted for different reasons. And
finally, civilizations have affected disease by their definitions of it. In the Western
Introduction 3

world, those definitions have most often been created by social, political, and
intellectual elites, whose aim has been to separate themselves from the poor or
the otherwise deviant. Here cultural constructions and material evidence feed
each other: as this book argues, the poor get not only the blame, but also the
Our uses of the word “disease” betray considerable uncertainty about its
meaning. For many people disease has an objective reality, apart from human
perceptions and social constructs. Henry Sigerist, writing in 1943, called disease
a “material process,” a “biological process,” which was “no more than the sum
total of abnormal reactions of the organism or its parts to abnormal stimuli.”1 In
this view there is little doubt about whether a person is or is not “sick,” and ill-
ness is a group of recognizable physical symptoms that may involve weakness,
incapacity, organ failure, malformation, or death.
This ontological view of disease carries further implications. First, disease
exists apart from human beings, because the “organism” in Sigerist’s definition
hardly has to be human. Disease may therefore have a separate history. Erwin
Ackerknecht, in his influential and useful survey of the history of medicine (first
published in 1955), tells us that “disease is very old, far older than mankind, in
fact about as old as life on earth. Our evidence tells us that disease forms have
remained essentially the same throughout the millions of years.”2 Second,
disease is a physical abnormality and is hence a fit subject for study by biological,
natural science. The extent to which we now think of the profession of medicine
as a “scientific” vocation testifies to the strength of this definition of disease. And
third, disease—at least in part and perhaps entirely—is produced by external
stimuli, apart from the normal human body. That disease exists “out there,” and
that it invades us, is a view that first gained particular currency in the late nine-
teenth century, especially because the persuasive power of explanations involv-
ing bacteria and viruses made those organisms seem the very essence of disease
itself. But even apart from the heavy criticism leveled at such positivism by the
views of cultural relativists, popular usages have always remained uncertain, and
the invasion model has never eliminated other conceptions. AIDS, some people
believe, is a condition brought on less by the invasion of an infective agent than
by internal moral degeneracy.
Nevertheless, it may be possible to accept Sigerist’s “objective” view of dis-
ease, if we also understand the social construction argument as well. Robert
Hudson (for example) puts the case: “Diseases are not immutable entities but
dynamic social constructions that have biographies of their own.”3 Historians,
especially those working in the long shadow of Michel Foucault, have found that
view particularly persuasive, and have joined anthropologists and sociologists in
awareness “that illness, health, and death could not be reduced to their ‘physical,’
‘natural,’ or ‘objective’ evidence.”4
4 The Burdens of Disease

In fact these views—both Sigerist’s (that disease is a biological process)

and Hudson’s (that it is a social construct)—may overlap. For a start, we may
imagine Hudson questioning Sigerist about his word “abnormal”: abnormal by
what standard? According to whom? And if Sigerist’s objective view may have a
relativist Achilles’ heel, even Hudson would confess that some “diseases” so con-
structed by societies are in fact “benign”; a social construct may define a condi-
tion as a disease, but it may have more trouble making people die of it. To be
sure, some past socially-constructed disease states have resulted in death, but
has spirit possession been responsible, or some other unrecognized organic
cause? But certainly social constructions of disease have led to the isolation and
stigmatization of many people in many different times and places, and in that
sense such constructions have had “real” effects.
Past realities reflect the ambiguous relations of these seemingly incompatible
understandings of “disease.” In this book I shall emphasize those diseases of the
past which—regardless of what societies called them—caused social disruption
by their biological processes that led to physical incapacitation and death. But
I am also concerned with the ways in which societies define and conceive dis-
ease, and so I shall discuss responses (some intellectual, some not) to diseases
as well. Cases in which human conceptions of disease result in social, political,
or economic change fall legitimately within the scope of this study.
Because this book principally concerns itself with “physical” ailments, I will
pay little attention to the role of mental illness in past societies. Modern histori-
cal writing has been especially sensitive to the social construction aspects of
mental illness. Roy Porter quotes the seventeenth-century Englishman who, on
being judged insane, exclaimed: “They said I was mad; and I said they were mad;
damn them, they outvoted me!”51 recognize that such cultural relativism is an
important aspect of “disease,” and that by omitting discussion of mental illness
I may lose the opportunity to provide some dramatic illustrations of social con-
structions. Different examples drawn from more plainly physical ailments may
make the same points, however.
I am particularly concerned here with epidemic diseases. “Epidemic” is not a
precise word. The Oxford English Dictionary, quoting the Sydenham Society’s
Lexicon of Medicine and Allied Sciences, defines an epidemic disease as “one preva-
lent among a people or community at a special time, and produced by some special
causes and generally present in the affected locality.” Most definitions agree that an
epidemic is temporary, affecting a particular place, and resulting in mortality and/or
morbidity in excess of normal expectancy. An epidemic is opposed to an “endemic”
disease, present or prevalent in a population all the time. But the definitions contain
no quantitative component. “Epidemiologists don’t use the word ‘epidemic’ much,
perhaps because they can’t always agree on what constitutes a significant excess,”
one textbook said in 1974. Another text, in 1996, despaired of the word: “How do we
Introduction 5

know when we have an excess over what is expected? Indeed, how do we know
how much to expect? There is no precise answer to either question.”6
This uncertainty also characterizes the more general or less technical uses of
the word. It has frequently been chosen to dramatize any problem, to convey
notions of both severity and temporal emergency; in 1937 Franklin Roosevelt
spoke of an “epidemic of world lawlessness.” Charles Rosenberg has argued that
those concerned with many different diseases have themselves bent the word
out of its precise meaning to lend drama to any disease “problem.” Thus another
epidemiology text (in 1974) proposed: “It would perhaps be well to label as
‘epidemic’ the long-term increases such as that noted for lung cancer. If this term
were applied, more action might be taken to investigate the causes and to insti-
tute control measures.”7 Long-term increases, not a temporary, exceptional sta-
tistical surge, could therefore be labeled “epidemic” if doing so would attract
more attention to the phenomenon.
My use of “epidemic” shares some of these ambiguities. This book focuses
on epidemics, but it includes other diseases that have had a marked effect on
past societies. Especially difficult to categorize are those diseases, endemic to a
society, that reached some unclear threshold of incidence that merited epidemic
status, perhaps as a result of environmental change. Typhus in the war-stricken
sixteenth century, tuberculosis in the industrial nineteenth, and AIDS in the glo-
betrotting twentieth might all be so described.
Epidemic diseases are generally associated with the word “infections,” and
indeed they are generally the result of an invasion by infectious agents such as
bacteria or viruses. Some—but not all—infectious diseases may also be called
“contagions,” in that they are communicated (directly or indirectly) from one
person to another, but other infections (bubonic plague, for example) may arrive
in other ways. Infectious, epidemic episodes (whether examples of contagion or
not) have had the most marked effects on past societies; effects were greatest
(especially in contemporary perceptions) when disease came as an unexpected
physical blow. Three further terms may characterize many (though not all) infec-
tious epidemics: “acute,” and “high mortality,” and “high morbidity.” “Acute” dis-
eases have rapid onsets, severe symptoms, and relatively short durations and
are contrasted with “chronic” diseases. “Mortality” means death rate, and mor-
bidity means rate of incidence of disease, both of which may soar in an epidemic.
In addition to infectious epidemics, the disease universe includes what
William McNeill aptly calls the “background noise” of endemic, chronic, and
degenerative ailments.8 The distinction between background noise and sudden
epidemic crashes has always been blurred; malaria, syphilis, and tuberculosis
may all be chronic, and all have been endemic in different societies, but at times
their mortality (whether real or perceived) justifies their inclusion here. As
Western civilization has brought many traditionally important epidemic diseases
6 The Burdens of Disease

under control, the background noise itself has become more audible. And the
modern background noises (especially cardiovascular diseases and malignant
neoplasms) deserve a separate treatment that this work makes no attempt to
One other limitation: I concern myself with “Western” civilization, meaning
that civilization which first emerged in western and central Europe between
about 400 and 800 C.E., from a fusion of Greco-Roman, western Latin Christian,
and Germanic-Slavic-Celtic roots, later spreading to the rest of Europe and to the
Americas. This chronological and geographical limitation I adopt partly for con-
venience (to keep the book manageable) and partly in the belief that Western
civilization’s experiences with, and reactions to, disease and illness are important
subjects in themselves.
Microorganisms have rarely been respectful of political and cultural frontiers,
however, and in this edition I have been even less consistent about limiting the
discussion to the West than I was in the first. The great twentieth-century
pandemics can really only be understood in their world contexts, which now
shape the ways in which Western society constructs them. On some level,
Westerners long regarded the 1918–1919 influenza pandemic as “forgotten”; but
as awareness of its colossal worldwide death tolls have spread, those facts have
contributed to contemporary fears of a new Asian-based influenza on a similar
scale. And as Europeans and North Americans gradually learned about the rav-
ages of AIDS in Africa, their constructions of the disease belatedly shifted from a
focus on deviant homosexuals toward more general heterosexual transmissions.
Western civilization has been extraordinarily expansive in the last five hundred
years, creating numerous give-and-take relationships between society and dis-
ease, as disease and concepts of it followed in the path of imperialism, diverted
its course, and were diverted by it. And while the age of formal imperialism has
largely passed, the world is more closely interlinked than ever, thanks to the
combined pressures of aggressive commerce, swift transportation, and phenom-
enal contemporary communication and information technology. Disease history
in the twenty-first century will be global.
Since the sixteenth century, the shrinking world has led to greater opportuni-
ties for the rapid movement of microbes to new populations; in the Western world
previously dominant religious and magical paradigms of explanation for disease
have been joined by others, adding new levels of complexity to human responses
to disease; and Western civilization has experienced massive social change,
many aspects of which have dramatically modified the human-disease relation-
ship. The position of disease in Western society has therefore become more com-
plicated than it has been in earlier centuries, and for that reason this book gives
what may seem a disproportionate weight to the more recent period. In doing so
I do not claim that disease played an unimportant role in the medieval world, or
Introduction 7

that the sufferings of medieval people have less meaning for us. Rather, I attempt
to clarify the new complexities of the last several centuries.
This edition draws on the rich scholarship of the past decade. I have particu-
larly revised the discussions of three great pandemics: the second plague pan-
demic, including the “Black Death” (in Chapter Three); the 1918–1919 influenza
pandemic (in Chapter Eleven); and the contemporary AIDS pandemic (in
Chapter Twelve). Controversies continue around the Black Death (and the larger
second pandemic of which it was a part): about its total mortality, its points of
origin, and (most vigorously) its causative organism. Chapter Three recognizes
those arguments, although it still holds with Yersinia pestis and its resultant bubonic
and pneumonic plague as the most likely—or perhaps the “least lousiest”—
explanation of it. While total mortality from the Black Death remains disputed,
historical estimates of the toll in the 1918–1919 influenza pandemic have steadily
risen, as its horrific worldwide extent is more clearly documented; and historical
and biological detection has recently (and triumphantly) traced its causative
virus. Chapter Eleven now reflects those new points. In 1998 (the date of this
book’s first edition), the AIDS epidemic still seemed more a topic of current
events than of historical analysis; Chapter Twelve now tries to take a current
view of that subject, especially of its African origins and African effects. Readers
will also discover other changes throughout that reflect new scholarship, and
will especially notice that the “Suggestions for Further Reading” have been
extensively updated.
The impact of disease on Western civilization, especially in particular episodes
or periods in which one disease seemed unusually formidable, is the central
theme of this book, the order of which is for the most part straightforwardly
chronological. The first chapter presents Western civilization’s intellectual inher-
itance: concepts about disease held by the ancient Greeks and Romans, and their
responses, to disease that later Western people adopted. Subsequent chapters
will include discussions of contemporary perceptions of a disease, its demog-
raphic, social, economic, political, and cultural/intellectual effects, and the ways
in which opinions, preventive strategies, and remedies all shifted over time.
More briefly, other sections will focus on the position of healers and general
ideas of healing; though not a history of medicine per se, this book does notice
the chronological evolutions of both the social positions of healers and the
dominant—or contesting— paradigms of disease.
Much modern historical writing has been devoted to particular aspects of these
topics; that body of scholarship has rightly emphasized the weaknesses of ear-
lier “positivist” histories of disease and medicine. Historical writing that scorns
the unlettered folk practitioner because she did not belong to a professional
guild, or that employs the wisdom of the present to denounce past therapies,
is simply not good history. I hope in this book to bring the views of modern
8 The Burdens of Disease

historical scholarship, as they have been applied so fruitfully to particular topics

in the history of disease and illness, to a broad synthesis of the subject. If at times
this narrative is critical of past beliefs and practices, I hope that such criticism
is tempered both by sensitivity to the underlying presuppositions of the past, and
by an awareness of the all-too-human shortcomings of the most recent responses
to disease.

The Western Inheritance

Greek and Roman Ideas about Disease

T he ancient Greek and Roman civilizations, and the Jews, early

Christians, and pagans who formed part of their populations, suffered from dis-
ease, saw their societies diverted by its effects, and developed a variety of ideas
and beliefs to deal with it. Ancient Greek civilization was a predecessor of the
West rather than an early stage of it, but extremely close intellectual and cultural
links tie the two together; in those respects the Western tradition began in
ancient Greece, and so some knowledge of ancient Mediterranean religious and
intellectual traditions is important for understanding the West’s general
approaches to the meaning of disease.

Asclepios, Hippocrates, and Galen

The Greeks both received direct transmissions from older civilizations
and had their own “prehistoric” cultural traditions and folklore. Many of their
responses to disease were derived from earlier traditions, which employed div-
ination, exorcism, pharmaceutical remedies, and invasive surgery. Greek atti-
tudes and practices also illustrated that the border between “supernatural” and
“natural” approaches could be very unclear, as it had been for the earlier
Egyptians. At some point in the fifth century B.C.E., if not earlier, some Greeks
may be said to have emphasized the natural approach, perhaps less ambiguously
than earlier peoples; but the distinction between that approach and others
remained one of degree, not absolute difference.
The best-known healing tradition of the early Greeks was associated with the
cult of Asclepios, a mythic hero who emerged as a lesser god in the Greek pan-
theon of the sixth century B.C.E. The sick would repair to the temple of the god and
perform ritual sacrifices and bathings, followed by a crucial “incubation sleep”

10 The Burdens of Disease

in which dreams and visions appeared to the sufferer. Those dreams either
healed directly, or gave directions (interpreted by the priests of the god) for an
appropriate therapeutic regimen, which might include bathing, rest, the admin-
istration of drugs, and attention to diet. The cult of Asclepios gained a wide fol-
lowing in subsequent centuries, extending into the Greco-Roman world as the
principal pagan religious response to disease. Particularly important centers of
the cult were in Epidauros, Cos, and Pergamum, but Asclepian healing was car-
ried on in many places, including some associated with hot springs and mineral
waters. The cult’s continuing vigor in the fourth century C.E. brought it into con-
flict with Christianity, as we shall see.
The Hippocratic tradition, named for the physician Hippocrates of Cos (c. 460–
c. 360 B.C.E.), had some of its roots in Asclepian temple medicine, but it also
included both older traditions of surgery and pharmacology and some newer
conceptions about nature. The Hippocratic Corpus, the body of about seventy
works on which our knowledge of the Hippocratic tradition depends, almost cer-
tainly had a number of different authors, who reflected differing emphases. But
much of the Corpus repeated Asclepian advice and themes: an attention to rest,
baths, and diet, combined with simple and gentle treatments and frequent expo-
sitions of the principle that “nature is the best healer.” Hippocratic writings also
illustrated careful observation and description of symptoms, notably in their dis-
cussion of the “fevers” that loomed large in ancient Mediterranean societies.
Hippocratic authors evidently had particular familiarity with malaria, chronicled
its intermittent (“tertian” or “quartan”) effects, and constructed general interpre-
tations of fevers around their “critical days.”1 In addition, Hippocratic authors
also relied on older beliefs from Greek folklore or Egyptian writings, which may
or may not have entered into Asclepian prognoses and therapeutics. Certainly
some of the pharmacological and surgical remedies of the Corpus antedate the
sixth-century emergence of the Asclepian cult.
Hippocrates and his colleagues, however, also lived in a vibrant period of
Greek philosophy, initiated in the previous century by the “nature philosophers”
such as Thales, Anaximander, and Anaximenes. Those thinkers had begun shift-
ing the balance between “supernatural” and “natural” explanations in the direc-
tion of the latter, and “natural” explanations of disease make a clear appearance
in the Hippocratic writings. A frequently cited Hippocratic passage proclaimed of
epilepsy: “I do not believe that the ‘Sacred Disease’ is any more divine or sacred
than any other,” and presented instead an explanation based on human heredity
for a disease that, involving as it may dramatic seizures, could easily be conceived
as a product of supernatural forces, spirits, or demons.2 At points the Corpus
speculated about environmental causes: “Those [diseases] peculiar to a time of
drought are consumption, ophthalmia, arthritis, strangury and dysentery.”
Heredity explained other (or even the same) disease states: “If a phlegmatic child
The Western Inheritance 11

is born of a phlegmatic parent, a bilious child of a bilious parent, a consumptive

child of a consumptive parent [then heredity might also explain epilepsy].”3
Some Greek attitudes toward disease came to include this strand of “rationalism,”
which de-emphasized the role of forces outside human control or understanding
and urged instead that human disease could be comprehended in human terms.
Such diseases might therefore be both understood and controlled by the exer-
cise of human reason.
Of particular later importance in the West was the humoral theory to which
Hippocratic authors contributed, which saw the health of the body dependent on
the maintenance of a balance among the “humors”: a surplus, or a deficiency, of
one humor or another led to disease. The clearest exposition of this notion

The human body contains blood, phlegm, yellow bile, and black bile. These
are the things that make up its constitution and cause its pains and health.
Health is primarily that state in which these constituent substances are in the
correct proportion to each other, both in strength and quantity, and are well
mixed. Pain occurs when one of the substances presents either a deficiency or
an excess, or is separated from the body and not mixed with the others.4

Such humoral theories of disease, and indeed of physiology, grew out of

Greek natural philosophy that both preceded the Hippocratic writings and
existed contemporaneously with them. At the center of Greek natural philoso-
phy in the fifth century B.C.E. was an interest in the basic substances (or “elements”)
that underlay all matter.
Of these element theories one of the most important, at least for later Western
history, was that of Empedocles (fl. c. 450 B.C.E.). Empedocles proposed that four
“elements” served as the fundamental constituents of all nature, and that those four
elements were in turn manifestations of essential physical qualities. Water embod-
ied wetness and coldness; earth, dryness and coldness; air, wetness and hotness;
fire, dryness and hotness. Empedocles’ element theory, and its association with
human physiology, was adopted by Aristotle (384–322 B.C.E.) , which accounts for
some of its later importance; Hippocratic authors also employed it, associating it
with certain “temperaments” of individuals as well as with the humoral theory of
disease. Much of the later influence of the humoral paradigm came through the
writings of Galen, and the humoral theory may be best seen in them.
By the time of Galen (129–c. 210 C.E.) a unified Greco-Roman civilization had
long been created across the Mediterranean, at least for the literate, prosperous
ruling classes. Galen, a physician from Pergamum, spent some time in Rome as
a physician to the emperor Marcus Aurelius. Galen was a very influential figure
in his own time, and became yet more so in later centuries as his doctrines
appealed to both medieval Christians and early Muslims. Galen stood at the
12 The Burdens of Disease

intersection of two important traditions of Greek medicine and thought about

disease and the human body. One was the Hippocratic and humoral approach;
the other was anatomical study, which undoubtedly had its roots in the surgical
practices of prehistory and (more especially) Egypt. Anatomy was pursued with
particular seriousness in the early Hellenistic period, when the traditions of
Greece and Egypt most clearly combined. Several “schools” of anatomy had sub-
sequently arisen that used anatomical evidence to argue fundamentally different
views of what went wrong with the human body. Some believed that specific
solid tissues of the body became diseased and that therefore disease was local in
character, restricted to one organ or set of organs. Others, following a line of rea-
soning consistent with the humoral theory, saw disease as a systemic problem:
fluids carrying humors moved through the entire system of the body, and unbal-
anced humors affected the entire system.
Galen’s picture of human physiology, derived from his anatomical ideas, was
an impressively complex one that involved three largely independent systems
conveying different fluids and “spirits” to the organs and tissues of the body. The
channels of conveyance in the three systems were the veins, the arteries, and
the nerves. The veins sprang from the liver, and were thus in turn associated
with the digestive system; food entering the digestive tract led to the creation of
“natural spirits” in the liver, and those spirits, the active principle of nutrition,
moved to the rest of the body through the veins. The veins served (among other
organs) the heart, wherein venous blood mixed with air, carried there from the
lungs; “vital spirits” resulted from the combination of air and venous blood in the
heart, and arterial blood carried these spirits, the breath of life, through the body
in the arteries. Both venous and arterial blood fed the brain, the seat of the third
system, that of the nerves. Nervous fluid carried “animal spirits,” the active prin-
ciple of animation, through the body.
Galen’s beliefs about anatomy and physiology recognized, to a remarkable
degree, that the definition of human “life” was a complex matter. Did the function-
ing of any single organ or system mark the difference between life and death?
Aristotle had regarded the heart as the seat of life; when it stopped, life stopped.
Galen was not so sure, and more recent thought, wrestling with “life” defined by
electrical impulses, should see in him a sensitive forerunner of modern dilemmas.
Galen’s three systems also involved the four humors, since he was heir to the
Empedoclean and Hippocratic traditions. As such he believed in the theory of
the four elements. Earth, water, air, and fire entered the body through food,
drink, and the atmosphere, and the processes of digestion and respiration con-
verted those elements into the four Hippocratic humors: fire into yellow bile, air
into blood, water into phlegm, earth into black bile. The humors made up the
body fluids, some of which (particularly blood, in its venous and arterial forms)
carried the “spirits” or active principles that caused the body to function.
The Western Inheritance 13

Galen’s explanation of human physiology thus clearly descended from the

“systemic” school, and may be seen as a sophisticated elaboration of it. If disease
was a product of the imbalance of the humors carried by the different systems,
the physician should restore the balance. And since ultimately the humors in the
body derived from the four elements, from what we eat and drink and breathe,
dietetic treatment played a major therapeutic role. For example, Galen reasoned,
“those articles of food which are by nature warmer are more productive of bile,
while those which are colder produce more phlegm.”5 This dietetic view of
health, related to humoral explanations of disease, could assume a highly moral
aspect.6 In Galen’s writings the moral emphasis was clear. Galen saw dietetic
medicine as a branch of moral philosophy; errors in one’s way of life, the individ-
ual’s ignorance and/or intemperance, produced internal disease: ulcers, gout,
digestive pain, arthritis, the “stone.” Hence proper behavior—habits of life and
diet—could avoid most disease. Although Galen may have emphasized the moral
elements of medicine to legitimize the physician’s social and intellectual posi-
tion, many generations of later Muslim and Christian thinkers agreed with him
about the connection between health and moral philosophy.7
Galen also represented the Hippocratic tradition in his professionalism as a
physician. The Romans among whom Galen lived generally did not “practice
medicine” as a profession. An extremely polytheistic people, the early Romans
explained disease as the product of the many gods who superintended each
household and indeed each part of the body. Heads of families performed the
appropriate propitiary rites and sacrifices to preserve family health, just as the
good Roman pater familias kept his tools and slaves in good working order.
Medical practice as a vocation fell to foreigners, especially Greeks. Greek physi-
cians throughout the Mediterranean lands had, over the centuries, found
Hippocratic principles consistent with successful practice; Greek physicians orig-
inally lived as itinerant craftsmen who had to establish confidence through cor-
rect prognoses and who could ill afford therapeutic failures.8 The careful
empirical descriptions of Hippocratic writing offered a safer basis for diagnosis.
The caution of the Hippocratic tradition, which (following Egyptian precedent)
included frequent modest decisions that some ailments were beyond a physi-
cian’s power to cure, safeguarded the practitioner from rash claims and dashed
hopes, and hence from angry accusations of failure. By the late second century
B.C.E., Greek medical practices had become influential in the expanding Roman
world, and by Galen’s time the Greek physician and the Asclepian temple were
social fixtures throughout the Mediterranean world.
Within Greco-Roman medical society a number of professional demarcations
remained unclear. Only the market determined the difference between a “legiti-
mate” physician and a “quack.” Further, the Greco-Romans made no attempt to
delineate “medicine” (or “science”) from “religion.” Physicians often remained
14 The Burdens of Disease

associated with Asclepian temples, and sacrifices and votive offerings remained
essential parts of all healing, “not merely a negative response” (as Ralph Jackson
neatly puts it) to the shortcomings and failures of medical treatment.9 And Greco-
Roman medical practice remained in most ways unspecialized. The later
European gulf between physicians and surgeons, between theory and practice,
did not come from Greco-Roman tradition; although (especially in the larger
cities) some specialization did develop (care of the eye and obstetrics/gynecol-
ogy, the latter often practiced by women), most surgical procedures simply
remained part of a healer’s general stock of remedies. Those remedies also
included a formidable body of materia medica, swollen by the territorial expan-
sion of the far-flung Roman Empire, which brought together many different peo-
ples and their herbal traditions. The Romans were a remarkably adaptable
people, who absorbed a wide range of beliefs and customs. But Christianity
proved difficult for Greco-Roman medical practitioners to digest.

Christian Theory and Practice

Christianity, which began as a sect within Judaism in the first century C.E.,
soon broke away from its clannish parent and, in time, proclaimed itself a univer-
sal religion. By the third century C.E. the faith had diffused widely over the
Roman Empire; although its followers remained a decided minority, its numbers
increased steadily in that century. Among the many reasons for the appeal of
Christianity was its radically different conception of healing, which deserves
attention both as another version of health and illness in antiquity and as an
important component of later Western beliefs.
From the start the early Christians formed a separate society in the ancient
Roman world. They refused (as did the Jews) to worship the official gods of the
polytheistic state, and so the orthodox Romans regarded them as “atheists”; and
while Christians (at least by the third century) could be found at many levels of
civil and economic society, they remained something of a world apart. Their con-
ception of disease grew out of their different religious view, and at least on the
surface their response to disease sharply contrasted with the ideas of high Greco-
Roman culture.
Some (though not all) of the early Christian attitudes toward disease can be
traced to the ideas of Judaism. The Old Testament contains many references to
diseases and their causes, and they clearly show that Judaism shared with
Mesopotamian cultures a supernatural view of the subject. Old Testament
stories often relate disease to errant behavior that has angered the god Yahweh.
For individuals, wanton conduct had consequences and adultery was especially
Two other emphases of the Hebrews also had particular later importance.
One was the notion that a god’s wrath could be directed against an entire offending
The Western Inheritance 15

people as well as against errant individuals. Thus Phineas and his colleagues
rebuked the Reubenites: “What is this treachery you have committed against the
God of Israel? Are you ceasing to follow the Lord and building your own altar
this day in defiance of the Lord? Remember our offence at Peor, for which a
plague fell upon the community of the Lord. . . . If you deny the Lord today, then
tomorrow he will be angry with the whole community of Israel.”10 From medieval
plague epidemics to twentieth-century AIDS, diseases have been seen as divine
judgments on subcultures or even on entire peoples who have strayed from the
presumed paths of righteousness.
The other emphasis was the association of disease and the “unclean.”
Chapters 13–15 of the book of Leviticus provide a thorough discussion of impuri-
ties (including diseases) and the rituals required to atone for them. Those impu-
rities are closely linked with skin diseases, and in some later ages the skin
diseases of Leviticus were taken to be leprosy (see Chapter Two). Leviticus does
not clearly associate those skin diseases with individual fault; rather, they are
marks of ritual uncleanliness. But the god is clearly displeased by the uncleanli-
ness. And further, the sufferer might be required to live in isolation: “So long as
the sore persists, he shall be considered ritually unclean. The man is unclean; he
shall live apart and must stay outside the settlement.”11 Did the unclean pose a
danger to the others by their very proximity? If so, impurity and disease were
contagious, and simple association with the impure might result in illness.
Certainly the Hebrews were not the only Mediterranean people to emphasize
cleanliness (however defined); but the Old Testament provided arguments
that linked physical imperfections, God’s anger, and disease, and thus suggested
the isolation of the unclean for the protection of the godly (and healthy)
The Judaic tradition, then, connected disease and God’s wrath, a wrath some-
times brought on by human misbehavior, a wrath that might be propitiated by
rituals. While the early Christians shared many of the ideas of the Jews, they
also lived in the expectation of the imminent end of the world, when Christ the
Redeemer would reappear and usher in a new kingdom. Perhaps because things
of the body therefore seemed transiently insignificant, perhaps because pagan
learning was not to be trusted, some Christians scorned the orthodox healing
routines of the Greeks and Romans. Perhaps the traditions of Hippocrates, or
Asclepios, were too closely associated with other gods, while the elaborate purifi-
cation rituals of the Jews represented the “law” that Jesus’s teaching had super-
seded. The Christians lived in a world entirely dominated by their god’s
immanence; disease and health, if they had any importance at all, acquired such
importance as manifestations of God’s power and will.
Further, demons populated the world. “Disease” to the early Christians (and
to some other segments of Roman popular culture as well) meant above all
16 The Burdens of Disease

possession by demons, whether that possession took the form of physical illness
or not. For the early Christian, then, “healing” most often meant the exorcism of
demons, an exorcism that might take dramatic physical form, as the sufferer
(actually the demon who possessed him) roared and shook as the demon was
expelled. What resulted was—to the early Christian, if not to the puzzled pagan
onlooker—“health.” The Christians and the pagans therefore employed different
definitions of disease and health, and a visit to a Christian service might be a far
different experience from a visit to an Asclepian temple or a Greco-Roman physi-
cian. So when we say that the Christianity of the third century (for example)
appealed to the Roman population as a “healing” religion, we must be careful
about what we mean by “healing.”
Yet some correspondences surely existed. Before the Passion, Jesus had
appeared to his followers perhaps most dramatically as a healer who could make
the lame walk, the blind see, and raise Lazarus from death itself. Such healing
powers, Christians believed, were transferred to Jesus’s apostles and then to the
disciples. Early Christian communities took on the nursing of the sick as an
important obligation. Some of the early growth of Christianity coincided with
periods of serious epidemic disease in the Roman world, notably the “plague of
Cyprian” in the mid-third century; the chronic pressure of malaria, tuberculosis,
and a variety of other ailments had long weakened the Roman physical fabric as
well. In such times the Christians both promised the power of a healing god and
practiced diligent care of their ailing colleagues. Did some Romans look to
Christianity as a source of solace for the body? Although one could not become a
Christian casually (at least before the fourth century), perhaps Christianity
gained followers in epidemic times as a healing religion.
In fact the relation of Christianity to classical culture was not simply one of
rejection. By the third and fourth centuries a number of Christian thinkers, espe-
cially such Greek Fathers as Origen and Basil, advocated a synthesis of classical
and Christian learning. Specifically they urged Christians to accept the medical
knowledge of the Greco-Roman world as one of God’s gifts. Those who practiced
Galenic medicine might be reviled, but they might also be praised for carrying
on a profession that illustrated the supreme Christian virtue of charity. The
Christian anargyroi, the healing saints, inspired cults whose practices resembled
those followed by Asclepios’ devotees. Their shrines and their relics, Timothy
Miller says, presented “more than the god Asklepios in Christian dress,” but the
therapeutics of each overlapped the other.12
Romans and Greeks alike had long offered sacrifices to the gods, and
Christians made offerings to the saints. Some of the anargyroi were historical
persons of early Christianity; others were clearly mythical figures, and some of
those were related to analogous Greek and Roman gods. Some saints, like the
localized gods of polytheistic paganism, specialized in particular ailments or body
The Western Inheritance 17

organs; St. Lawrence, for example, martyred by roasting, had special care of the
back. The Asclepian tradition’s emphasis on the role of dreams in both progno-
sis and therapy was mirrored in the appearance, to Christians, of the healing
saints Cosmos and Damian in dreams. The bathing rituals of Asclepian medicine
found an analogue in Christian baptism and sprinkling with holy water. The
dietetic approach of humoral medicine could be given a moral interpretation,
and could thus be brought into harmony with a view of disease as a consequence
of misbehavior. At least some Christian holy men cooperated with physicians,
using profane remedies as well as performing exorcisms and miracles.
By the fourth century, especially in the eastern part of the Roman Empire,
healing in Christian communities bridged the medical and ecclesiastical worlds.
Priests and physicians alike might be found at the shrines of the anargyroi. The
first true hospitals—meaning places that provided beds, food, nursing care, and
medical therapy to all classes of the population, with the intention of restoring
the sick to health—emerged (according to Miller) from this combination of
Christian charity with the classical-Christian synthesis urged by the Greek
Fathers. When Christianity suddenly gained favor at the imperial court (under
Constantine, 313–337) and then became the official religion of the Roman Empire
(under Theodosius, 379–395), the cult of Asclepios was perceived as a danger-
ous rival that worshipped a competing healer-savior, and the destruction of some
Asclepian temples followed. But if Miller is correct, pagan followers of Asclepios
may have felt some of the same ambivalence toward the “rational” world of
Galenic medicine that bothered their Christian successors. The early hospitals
apparently drew on some of the traditions of the anargyroi cults (of Cosmos and
Damian, for example), but those in turn had borrowed from Asclepios, and all
had overlapped with Galenism. Thus Theodore of Sykeon, a Byzantine holy man
who died in 613, prescribed folk medicines, applied salves, and massaged limbs.
According to Peregrine Horden, stories of Theodore’s career contain “descrip-
tions of acts of healing which seem to efface whatever imprecise boundaries we
might care to draw between the medical and the miraculous.”13 Aline Rousselle
has found a similar mixture of classical-Galenic, folkloric, and Christian healing
practices in fourth-century Gaul.14
The old Greco-Roman medical orthodoxy felt pressures other than the obvi-
ous political ones that stemmed from the empire’s conversion to Christianity. In
the western part of the empire, where more drastic social and economic change
occurred, threads between Christianity and classical culture snapped more deci-
sively. Peter Brown, contrasting the healing of the Christian Martin of Tours and
the pagan Marcellus of Bordeaux in the fourth century, notes that Marcellus
lived in a society that had lost touch with learning, cities, and professional physi-
cians; what Marcellus could offer was a manual of traditional folk remedies that
might enable an individual to enter into a wide world of magical sympathies and
18 The Burdens of Disease

forces.15 Brown’s Marcellus and Horden’s later Theodore may be seen as occu-
pying different points along a continuum of approaches to healing. Marcellus
purveyed folk medicine in which elements of magic punctuated natural explana-
tions and empirically derived procedures. Theodore, a Christian, performed mir-
acles and exorcised demons, yet he applied natural remedies himself and
referred some sufferers to others who specialized in them.
The empirical and philosophical approaches that emphasized a “naturalistic”
conception of disease never had a firm and unambiguous hold on the Greco-
Roman mind. That hold became much weaker by the fourth century, in part
because of the pressure of successful Christian competition and in part because
the social conditions for the maintenance of a specialized urban healing culture
had changed. By the sixth century direct acquaintance with the texts of
Hippocrates, Aristotle, the Alexandrian anatomists Herophilos and Erasistratos,
and Galen had virtually disappeared from the western part of the old Roman
Empire. The eastern half retained some hold on such texts. The Arabs who swept
over Egypt, North Africa, Spain, Palestine, and Syria in the seventh century
reestablished the Galenic traditions, but in the Christian West the ancient Greek
ideas of naturalism did not resurface until after 1000.

Medieval Diseases and


M ost historians now accept the idea that “Western” civilization emerged
sometime between 300 and 800 C.E., a fusion of elements of Greco-Roman civiliza-
tion (including the Christian religion or at least its Latin branch) and the Germanic,
Slavic, and Celtic peoples of northern and eastern Europe. The “Middle Ages” con-
ventionally begin in that period and extend down to some time between about 1350
and l550, when they were succeeded by what is called the “early modern” period.
The “Middle Ages”—to which the term “medieval” is applied— should therefore
more properly be called the “Early Ages” of Western history.
Until about 1000, Western life was overwhelmingly agricultural, long-distance
or specialized trades were few, town life almost nonexistent, political authority
highly fragmented, literacy rare. Some important discontinuities therefore
existed between the early Middle Ages and the ancient Mediterranean, disconti-
nuities that affected the disease environment. The early West, profoundly rural,
lacked the urban concentrations that encouraged such airborne or “crowd” dis-
eases as tuberculosis, influenza, and diphtheria. Diseases of the digestive tract
may not have spread as rapidly either, although sanitation was, if anything, less
One catastrophic plague pandemic did strike late antiquity between 541 and
about 750, and its effects on mortalities, societies, and economies may have con-
tributed to the transition from “ancient” to “medieval” civilizations in both East
and West. After that visitation abated, major epidemics were largely (and per-
haps fortuitously) absent from the West until plague returned in the fourteenth
century. But early medieval people also lived in very close proximity to their ani-
mals, so zoonoses (diseases that moved from animals to humans) persisted. So
too did dietary deficiencies (of protein, iron, vitamins), spoiled foods, and their

20 The Burdens of Disease

resultant diseases: rickets, scurvy, ergotism. Greater continuity existed in the

realm of attitudes toward disease and health, where the gradual transition begun
in late antiquity from pagan to Christian views and from responses based on lit-
erate traditions to those rooted in oral folklore continued in the early West.
Between about 1000 and 1300 cities grew up, the local self-sufficiency of eco-
nomic life broke down as trade and specialized crafts increased, political com-
plexity and authority grew, and a rich and sophisticated culture emerged.
The disease context changed accordingly. Those remarkable developments in
Western history that began accelerating around 1000 were accompanied by, per-
haps preceded by, and in some senses caused by a rapid increase in population.
At the root of that population increase may have lain some combination of
improved agricultural techniques (hence more and better nutrition), benign cli-
mate, and the relative absence of serious epidemic diseases. On the base of a ris-
ing population could be built more varied economic opportunities, improved
political security, and a refined religion and ethos that inspired greater respect
for human life, all of which in turn magnified the population increase. The popu-
lation as a whole was almost certainly “healthier” in 1150 than it had been in 900,
for some combination of the above reasons. But as will be shown later in this
chapter, conditions for a revival of serious epidemics had also been created.
In the years after 1000, and especially after about 1100, Western thinkers
began rediscovering the works of the ancient Greeks and Romans. In many cases
these discoveries occurred through the intermediary work of Muslims, so that
such Arabic authors as al-Rhazes and Avicenna deeply influenced Western
medieval thought. But however they reached Western thinkers, the “new” ideas
made a staggering impression. By the thirteenth century Aristotle was simply
the Philosopher, the master of all who knew. As we have seen in Chapter One,
the early Western Christians had often scorned the classical explanations
of the natural world, explanations that seemed of little importance when set
beside knowledge of God and a spiritual or supernatural eternity. But for what-
ever reason, twelfth-century European intellectuals became enormously excited
by the astronomical ideas of Ptolemy and by the anatomical and etiological theo-
ries of Galen. In the course of the twelfth and thirteenth centuries schools in
European towns evolved into “universities,” in which the new ideas of classical
antiquity were taught in harmony (or so it was hoped) with Christian doctrines.
Among the disciplines that emerged in those years was formal medicine, and
physicians began to assume separate professional status, dependent on post-
graduate university training and qualifications.
The effects of these new ideas and this new profession on disease and health
remained slight, however. Better health, or an increased life span, or a lower rate of
mortality did not result from an actively more successful “medicine.” The medical
profession and the theory of disease underwent important changes in the medieval
Medieval Diseases and Responses 21

period, but those changes had relatively little effect on mortality or health. The
ideas of Galen often meant little change in practices, and in any case the formally
trained physician who employed them might be found only in larger towns.
Although some people from all social classes consulted such physicians, the upper
classes most often enjoyed their benefits (if benefits they were). For most of the
medieval population, healing remained intimately associated with religion, espe-
cially with its popular manifestations, which included an ambivalent mixture of
prayers to saints both recognized and not, charms, and a variety of traditional “med-
ical” responses, particularly herbal. Examples of some of these different responses,
both Galenic and traditional, emerge from a closer examination of two diseases
that attracted particular attention in the central Middle Ages: leprosy, about which
the ideas of the official religion strongly affected medieval responses, and scrofula,
around which a variety of political and magical ideas clustered. More such exam-
ples will follow in Chapter Three, which concerns the great medieval plague epi-
demic, and in Chapter Five, which will explore more systematically the relations
between magic, religion, science, medicine, and popular healing practices.

In the centuries before the fourteenth Europeans experienced many
diseases, but one—leprosy—attracted the most attention. Historical writing
about medieval leprosy has been dogged by problems of identification and even
etymology, and some discussion of what leprosy was and is will clarify both
medieval responses and historical views of them.
Leprosy is now most often called Hansen’s disease, taking its name from the
nineteenth-century investigator who discovered the bacterium responsible for it.
That bacillus, Mycobacterium leprae, may be responsible for a number of differ-
ent manifestations or types of disease. It may or may not be very communicable,
depending on the individual case; in most cases it can be communicated only
after a prolonged and close exposure, and even then hereditary powers of resist-
ance may intervene. Its incubation period is quite long; that is, a prolonged period
of years separates infection and visible symptoms. The last fact especially com-
plicates the epidemiology of the disease.
Hansen’s disease, especially in the form called lepromatous leprosy, eventu-
ally manifests itself in dramatic symptoms. Lesions toughen the skin of the face;
the lesions worsen and destroy nerves and tissues. Serious deformities may
result, as facial bones are damaged or destroyed and the extremities become
misshapen or “fall off” entirely. Such symptoms are repellant, to be sure, and so
sufferers of the disease attract attention by their mere appearance. But some of
the symptoms, especially if they are imprecisely described, are not unique to
Hansen’s disease; advanced stages of syphilis and yaws may produce some of
the same effects, for example, and the number of diseases that result in skin
22 The Burdens of Disease

lesions is legion. Some historians have questioned whether medieval “leprosy”

was really Hansen’s disease at all. Did medieval diagnosticians loosely group
a panoply of ailments under the blanket—and condemnatory—word “leprosy”?
A second historical question enters into that problem: what connection exists
between medieval leprosy and the disease stigmatized in the Old Testament
book of Leviticus as a mark of impurity? Leviticus provided an important source
for medieval responses to “leprosy”; were those responses consistent with the
ancient Hebrew traditions?
It now seems that what medieval people called “leprosy” really was Hansen’s
disease, lepromatous leprosy. Although there undoubtedly occurred many mis-
diagnoses, medieval definitions turn out to have been remarkably good. The
most convincing evidence comes from paleopathology. Cemeteries known to
have been set aside for “lepers” have been exhumed, notably in Denmark, and
the skeletons (or a high percentage of them) show damage of the kind caused
exclusively by lepromatous leprosy; the same damage is not found in the bones
from other, more “general,” burial grounds.1 Modern students of medieval lep-
rosy have also argued that medieval descriptions of leprosy are consistent with a
diagnosis of Hansen’s disease; Luke Demaitre, who concurs with their views on
the accuracy of medieval diagnosis, adds arguments against the likelihood of a
confusion with syphilis, a subject to which we shall return.2
Medieval Europeans mistakenly thought the leprosy suffered by their con-
temporaries was the same disease referred to in Leviticus 13 and 14, a connec-
tion that made the lot of the medieval leper even more miserable than it might
have been. This mistake emerged from a historical and etymological tangle.
Leprosy— Hansen’s disease, lepromatous leprosy—may or may not have been
known in the ancient Near East. In Leviticus, the Hebrew word tsara’ath, roughly
meaning (according, to E. V. Hulse) “repulsive scaly skin-disease,” is very thor-
oughly discussed as a serious matter offensive in the sight of God.3 The chapters
describe careful examinations to be undertaken by priests, who decide if the suf-
ferer has tsara’ath; if the answer is yes, the sufferer is pronounced unclean, and
Leviticus 14 specifies elaborate sacrifices and rituals that when performed atone
for the uncleanliness and thus appease the angry god. Leviticus further insists
that the sufferer be isolated from the community until he is clean.
The Greek language rendered the Hebrew tsara’ath as lepra, but the Greeks
were also familiar with Hansen’s disease, for which good descriptions may be
traced to the Hellenistic period. The Greeks called that disease elefantiasis, and
it was under that term that Hansen’s disease (medieval leprosy) existed in the
Greco-Roman civilization. In modern terms elephantiasis is yet another disease,
a chronic lymphatic complaint found most often in the tropics. This latter
disease—modern elephantiasis—was known to the Muslims, who used a term
equivalent to the Greek elefantiasis (by which the Greeks meant Hansen’s
Medieval Diseases and Responses 23

disease) to describe it. A different Arabic word was found for Hansen’s disease
(juzam). When the revival of learning associated with Arabic authors began
in Europe, a fatal etymological misunderstanding arose. The Arabic juzam—
Hansen’s disease— should have been equated with the Greek elefantiasis, which
had no particular ritual or religious significance. But because Arabic had already
used a similar word for what we now call elephantiasis, Latin scholars equated
juzam with the Greek lepra and hence with the Hebrew tsara’ath.
Hence the “scaly skin disease” of the Hebrews, the mark of a ritual uncleanli-
ness, was equated by medieval Christians with leprosy, a disease that in ancient
Greece and Rome (and in the world of medieval Islam) was known and had no
such ritual associations. In addition, medieval Christianity placed different
emphases, or perhaps even different meanings, on the concept of uncleanliness.
How much was uncleanliness brought on by the sufferer’s wrongdoing, or by his
sin? According to Saul Brody, the most thorough modern student of medieval lit-
erary responses to leprosy, the original Hebrew intent divorced “ritual uncleanli-
ness” from “moral guilt.”4 Later medieval Christian writers erased such
distinctions, perhaps with some Old Testament support, for it is certainly true
that the God of the Old Testament frequently punished wrongdoing with disease.
Leprosy was found in the early centuries of Western history, for skeletons
from the fourth and fifth centuries show leprous damage and laws commenting
on leprosy date from the early Carolingian period of the Franks, in the eighth
century. But comment about leprosy, consciousness of it, and vigorous response
to it all peaked in the years between about 1000 and about 1250, coinciding with
the period of rapid European population growth. In those years leprosaria, or
other forms of leprosy “institutions” or communities, were founded in consider-
able numbers, and the Church formalized its rituals in response to an evidently
widespread disease. Reports of leprosy began declining between 1250 and 1350,
so that when the great plague epidemic began in the late 1340s many leprosaria
had already been gradually depopulated. Leprosy became rarer yet on the heels
of the plague epidemic, and by 1500 it was unusual, except apparently in
Scandinavia, where it persisted through the early modern period and even
revived in intensity in the early nineteenth century.
In the years between 1000 and 1250 leprosy was the subject of heavy ecclesias-
tical and legal intervention. Sufferers became the objects of harsh laws that might
sever them from society. Although the laws varied from one community to the
next, and may not always have been enforced, the leper might find himself (or
herself) ostracized by legal pronouncement. The process might begin with a pub-
lic accusation made by neighbors. An examination followed, often conducted by a
priest (as specified by Leviticus 13), but committees of magistrates and physi-
cians (especially later in the Middle Ages) might be involved as well. Clearly a real
possibility of misdiagnosis existed. In 1179 the Third Lateran Council formalized
24 The Burdens of Disease

the leper’s separation from the community into an awful ritual. The leper knelt
before the church altar under a black cloth, with a black veil over his face. An
office for the dead was pronounced over him, and the priest threw spadefuls of
earth from the cemetery on him. The priest then read a series of prohibitions:

I forbid you to ever enter the church or monastery, fair, mill, marketplace, or
company of persons. I forbid you to ever leave your house without your leper’s
costume, in order that one recognize you and that you never go barefoot. I for-
bid you to ever wash your hands or anything about you in the stream or in the
fountain. . . . I forbid you to touch anything you bargain for or buy, until it is
yours. I forbid you to enter a tavern. . . . I forbid you to live with any woman
other than your own. I forbid you, if you go on the road and you meet some
person who speaks to you, to fail to put yourself downwind before you answer.
I forbid you to go in a narrow lane, so that should you meet any person, he
should not be able to catch the affliction from you. I forbid you, if you go along
any thoroughfare, to ever touch a well or the cord unless you have put on your
gloves. I forbid you to ever touch children or give them anything. I forbid you
to eat or drink from any dishes other than your own. I forbid you drinking or
eating in company, unless with lepers.5

After this pronouncement the leper donned his distinctive costume and was led
outside the town walls to the leprosarium that would henceforth be home. The
priest offered consoling words, urging patience and trust in God’s mercy.
The priest’s prohibitions suggest that several different but complementary
views existed about leprosy. On one level the leper presented a religious, ritual
danger to the community, in line with the text of sacred scripture. That view was
especially important in the early years of concern about leprosy, when it led to
isolation that had many overtones of religious penance.6 Life in some leprosaria
included some of the features of monastic devotional obligations, and the pre-
scribed dress was clerical in style. Belief that the disease was a heaven-sent pun-
ishment for sin was widespread. According to Brody (and to Richard Palmer), the
sin most often held responsible was lechery; lepers were schemers and deceivers
who cuckolded the faithful, and they burned with overpowering sexual urges.7
Whether as a ritual defilement or as a punishment for grave misconduct, leprosy
was a fit subject of clerical intervention. And as Palmer points out, the medieval
church placed great weight on the importance of formal confession as a therapeu-
tic tool. A series of papal bulls and pronouncements between the thirteenth and
sixteenth century obligated physicians to call in priests for their patients, because
at least in some cases the disease might be cured by confession.
From the twelfth century on, physicians in the “new” Galenic tradition began
adding other emphases, more focused on the body than on the soul. Galenic
humoral medicine offered more detailed rationalizations about symptoms, and
Medieval Diseases and Responses 25

especially believed leprosy to arise as a disorder of one humor: black bile. Black
bile, overcooked and “burnt,” affected blood in turn, and that accounted for such
symptoms as “hideous” lips and fetid breath.
Physicians (and others) particularly associated the disease with fornication,
an act that actively disturbed two of the humoral “non-naturals” (exercise and
excretion). Maintaining a proper balance of such non-naturals was essential for
health, and the sex act might threaten that balance. Intercourse with a leprous
woman was a “particularly predictable cause,” a belief that neatly joined humoral
explanations, fears of contagion, and gynephobia.8 Some opinion, following the
most direct humoral route, saw leprosy as dietetic, the product of bad meat and
wine. And it is worth noting that physicians rarely referred to the biblical texts of
Leviticus when they wrote about the disease.
Ancient authorities also contributed two other causal concepts about leprosy:
that it was hereditary, and that it was contagious. Hippocratic texts generally
endorsed hereditarian notions; sanguine parents or bilious parents produced
sanguine or bilious children. Conception by a leprous mother, or being nursed
by a leprous mother or wet-nurse (an idea that combined hereditarian and conta-
gionist strands), might cause leprosy.
Concepts of contagion were also applied. Arataeus of Cappodocia (a contempo-
rary of Galen) had discussed flight from leprosy, and Muslim authorities were
drawn to that concept, although with reservations owing to their faith’s overriding
conviction that all diseases were heaven-sent.9 A contagionist idea entered the
1179 prohibition cited above: “I forbid you to go in a narrow lane, so that should
you meet any person, he should not be able to catch the affliction from you.” By
the later Middle Ages the doctrine of contagion was more and more frequently
applied to leprosy, perhaps because contagionism seemed to explain other dis-
eases (especially plague), perhaps because physicians came to have more influ-
ence in the diagnosis and proclamation of lepers. In the case of leprosy the
contagionist argument also gained strength from the Levitical horror the disease
inspired and the isolation insisted upon by the scriptures. Physicians in the four-
teenth and fifteenth centuries who decided that leprosy was contagious had to
reach that conclusion in the face of powerful contrary evidence, particularly the
frequent cases of lepers who did not pass on the disease to their spouses. Despite
that evidence, by the fifteenth century lepers were being compelled to enter hos-
pitals or leprosaria, and—more telling—expulsion from leprosaria for misconduct
no longer occurred, as it had when the leprosarium was a place of devotional
isolation; the leprosarium had become an isolation ward for contagion.10
Was there any hope of cure? Perhaps not much, but physicians certainly pre-
scribed regimens that they hoped would attack leprosy’s causes and palliate its
symptoms. Diets should avoid acidic or salty foods, sex should be shunned (in fact
some authorities urged castration), and the burnt humors (black bile and blood)
26 The Burdens of Disease

should be purged. Folk remedies (“Take a bushel of good barley in the month
of March, add half a bushel of toads”) abounded. The leper might hope for mira-
culous intervention for a cure, but even that might be suspect. Both the Church
and physicians looked askance on the claims of irregular or folk healers to cure
leprosy, and such claims might be taken as prima facie evidence of witchcraft.
Without such a miracle, lepers faced a lifetime of isolation in the leprosaria.
These institutions varied widely. Surviving regulations of the larger leper houses
of the thirteenth and early fourteenth centuries suggest that some enjoyed good
supplies of drink, food, and fuel. In some cases the property of the lepers was left
untouched, so that their wealth accumulated in the leprosaria. But such cases
were probably unusual. Even if the upper orders suffered disproportionately high
rates of leprosy, the majority of medieval lepers were poor; while some rich lep-
ers took advantage of high admission fees to use a leprosarium as a posh nursing
home, lepers and leprosaria were too often the objects of charity, and that charity
always depended shakily on the general level of prosperity. Lepers paid admis-
sion fees to the administration of the leprosarium, and brought their movable pos-
sessions; a particularly poignant detail was the requirement that lepers supply the
wood and nails for their own coffins when they entered the leprosarium.11 Most
frequently small and poor leprosaria survived on the fees squeezed from their
occupants and on uncertain local charity, customary dues, and payments in kind.
Even when the leprosarium had some potential assets, the lepers did not control
them: alms were collected by a “proctor,” or administrative official; and, as some
English law cases of the 1290s illustrate, those enjoying guardianship of a leper
hospital might abuse their position and enrich themselves.12
Originally the leprosaria developed under Church control, but as the medieval
centuries advanced lay political authorities assumed power over many of them. In
some cases these institutions could be prisons for people declared legally dead.
Lepers might lose ownership of their property as well as their rights to make con-
tracts or to inherit, although such restrictions varied with time and place. Their
property might in some cases devolve upon a seigneur. The position of spouses
presented a legal and theological tangle; in some cases the spouse of a leper might
be regarded as a widow and allowed to remarry, while in some leprosaria hus-
bands and wives might both live, but often in quarters segregated by sex.13
The isolation of lepers in separate institutions might mean danger for them,
for leprosaria collected an identifiable minority in one place.14 On at least one
disastrous occasion—in France in 1321—society turned on the lepers with fierce
royal proscriptions and murderous local assaults. Wide-spread rumors, amount-
ing to mass delusion, claimed that lepers, together with Jews and Muslims, were
engaged in a plot to poison true Christians everywhere. The “plot” had the char-
acteristic features of an imagined conspiracy by heretic outsiders: oaths, secret
meetings, and significant blasphemous gestures such as spitting on the crucifix.
Medieval Diseases and Responses 27

Jews and Muslims were traditional victims of the persecutions that followed such
delusions, but Malcolm Barber also argues that the strains on medieval society
in the early fourteenth century (to be discussed more thoroughly in Chapter
Three), such as increasing famine and the growth of vagabondage, created a cli-
mate for “conspiracy” theories directed against a variety of outsiders or “closed”
groups. The religious order of the Templars came under such an attack in France
between 1307 and 1312, for example. The lepers, who lived in distinctive com-
munities, whose physical repulsiveness was associated with moral failure, and
who had already been the subjects of an accusatory process at the beginning of
their isolation, were almost logical victims of such an outburst. People whose
humors were so badly out of balance surely were capable of concocting magic
poisons from the feet of toads. Lepers might also be involved in a more local
social conflict. In the 1290s the lepers of West Somerton violently resisted the
Prior of Butley who claimed that leprosarium property was his, not theirs; the
lepers seized some goods and smashed some others, in a case that illustrated
that the unclear legal position of lepers could lead to violence.15
But, as Brody suggests, the leprosaria could also serve as refuges from a hos-
tile world. Some people actually asked to be adjudged lepers, perhaps to gain
admission to such a haven, perhaps to gain what amounted to a license to beg.
And the “hostility” of the world was in fact inconsistent, both in practice and in
theory. The laws restraining lepers often simply didn’t work, or were not
enforced. Perhaps that was so, as both Brody and Palmer argue, because of
ambivalent medieval religious attitudes toward leprosy. On the one hand the lep-
ers were outcasts from society, morally corrupt, stigmatized by God because of
their sins. Their appearance inspired repugnance.
But at the same time it was also widely believed that lepers had in some way
been singled out for divine grace, the symbols of suffering for us all, the suffering
that would lead sinners to repentance. Jesus had suffered too. Perhaps the idea
that lepers were the chosen of God was simply offered as consolation, but many
people believed it. Certainly pious people, from kings down, gave alms to lepers.
This ambivalence may explain why so many lepers escaped confinement in their
leprosaria and why so many medieval street scenes involve lepers freely wander-
ing, begging, and wielding their sad clappers to warn the clean of their approach.
Estimates of morbidity or mortality from medieval leprosy are extremely prob-
lematic, as indeed are attempts to specify medieval populations as a whole. One
source claims that some 19,000 leprosaria were founded in Europe in the Middle
Ages.16 Rotha Mary Clay, in her careful survey of English medieval hospitals,
identified 222 hospitals for lepers, or leprosaria, founded in that country between
the eleventh and the fourteenth centuries, but even that seemingly precise num-
ber tells us little about the total population affected.17 Most of those foundations
must have been very small; whatever the numbers affected by leprosy, no
28 The Burdens of Disease

modern authorities have suggested that morbidity or mortality remotely

approached that of plague in the mid-fourteenth century, and it is probable that
other diseases such as tuberculosis took a greater toll on populations even at the
height of the leprosy scares in the twelfth and thirteenth centuries.
Leprosy disappeared from Europe relatively suddenly (outside Scandinavia);
its disappearance remains an enigma for historians of disease. It is tempting, for
instance, to see a connection between the sudden appearance of plague in
1347–1350 and the rapid decline in leprosy coincident with it. Plague may have
played a role in leprosy’s decline, but that role was social and intellectual, not bio-
logical. Stephen Ell has shown that plague’s biological effects on lepers cannot
have been great, for leprosy apparently confers some immunity from plague.18
But leprosaria were heavily dependent on the charity of others, charity both of
gifts and of services. The short-term economic and social disruption caused by
plague in 1347–1350 meant terrible hardship for lepers in their communities, and
probably meant the failure of leprosaria as well as the scattering of their inhabi-
tants and their subsequent physical weakening as a result of neglect and hunger.
Plague, therefore, contributed to decreasing the incidence of leprosy by weaken-
ing the social network of care and thus increasing the mortality of lepers.
Changing intellectual conceptions of disease also influenced the perceived
incidence of leprosy. As Demaitre argues, physicians came to have an increasing
role in the diagnosis of leprosy. We may be persuaded by Danish bones that
medieval leprosy really was leprosy, but some doubt remains that twelfth- and
thirteenth-century village clerics always made an accurate diagnosis before they
packed off a manor’s nuisance to a leper “hospital.” If Demaitre and others are
right that by the fourteenth century physicians were both better at diagnosis and
more involved in it, the number of “lepers” in the society might well have
declined as a result of changing diagnostic procedures. Plague’s appearance may
have contributed to etiological thinking as well. As we shall see in Chapter Three,
the universality of plague made it more difficult to sustain the notion that an indi-
vidual’s sin caused disease. The causal notions about leprosy began a gradual
shift in the direction of contagionism, and hence may have passed out of the
fevered comment of Church authorities.
William McNeill, in Plagues and Peoples, advanced the ingenious idea that the
decline in leprosy was related both to plague and to syphilis.19 His theory depends
on a belief that “leprosy” was often misdiagnosed in medieval times, and that one
of the diseases from which some “lepers” suffered was actually yaws, a relative of
syphilis (see Chapter Four). Yaws, according to McNeill, may have been com-
monly spread in medieval Europe by skin contact, but the depopulation of the
fourteenth century caused by plague resulted in a higher per capita income and a
greater availability of clothing and bedding, which in turn decreased skin
contacts in situations such as sleeping. Yaws eventually reemerged as a “new”
Medieval Diseases and Responses 29

disease, syphilis, in the late fifteenth century, having found a new skin-to-skin
contact route, namely the venereal one. Some parts of this theory are more prob-
able than others. Although plague did result in higher per capita income, and
probably a greater availability of bedding, the theory depends on assuming a wide-
spread medieval misdiagnosis; the paleopathological evidence for either yaws or
syphilis in pre-fifteenth-century Europe is thin; and discussions of the cuddling
habits of cold medieval Europeans remain very hypothetical.
A much stronger epidemiological case relates leprosy and tuberculosis. Those
diseases are close bacteriological relatives, both the products of mycobacteria. At
different points in history, both have created major social problems as chronic,
debilitating diseases; the victims of both have been rejected or stigmatized by soci-
eties whose members have been unwilling or unable to care for the chronically ill
and weak. The diseases apparently share some cross-immunity, more clearly from
leprosy as a result of tuberculosis infection than the other way. Tuberculosis
spreads much more rapidly and readily; it is far more contagious than leprosy.
Tuberculosis is often contracted in childhood or infancy, and a person so infected
would be an unlikely later victim of leprosy. Tuberculosis is also a disease that
flourishes in dense human populations, so it has been argued that as Europe
became more urban in the years between 1000 and 1300, it gradually provided
more favorable conditions for the spread of tuberculosis. Indeed Keith Manchester
has suggested that oscillations of tuberculosis and leprosy may follow levels of
urban concentration: leprosy gradually displaced tuberculosis as the more urban
civilization of Rome gave way to the profoundly rural early western Middle Ages,
then gradually surrendered as urban life in the West emerged, bringing a revival
of tuberculosis that intensified down into the nineteenth century.20
The part of the theory that relates a decline in leprosy to the growth of towns
is attractive, but it cannot be a complete explanation for leprosy’s disappearance,
if only because medieval Europe always remained predominantly rural; the rise
of its cities certainly had important historical effects, but their populations
remained a minority on the Continent as a whole. It is interesting, however, that
the lingering strongholds of leprosy in Europe were in thinly populated
Scandinavia, Greece, and Portugal.
Leprosy serves as a touchstone for examining many medieval conceptions of
disease. God, and God’s anger at individual sin, was an important cause. Disease
therefore stood as an important moral lesson. The Church claimed—and was
granted by opinion—considerable authority, both in diagnosis and in therapeutics,
for divine causes demanded sacred remedies. The ideas of the ancient Greeks,
mediated by Arabic writings, formed another set of responses, some of which over-
lapped with the moral and divine interpretations of Christian belief and provided
rationalization for it. Etiological ideas coexisted somewhat uncomfortably: disease
might be attributed to contagion, heredity, individual responsibility, and divine
30 The Burdens of Disease

whim; and those explanations have remained in uneasy yoke in the Western world
since medieval times. Finally, disease—including both its causes and its cures—
interacted with cultural beliefs and expectations. “Cures” may have “worked”
because they were expected to work. Because leprosy was so closely related to sin
and divine wrath, its “cures” remained largely in supernatural hands.

The Royal Touch

Very old connections exist between kingship and magic powers over
nature; some of the earliest “kings” of ancient Near Eastern city-states may have
achieved their political positions as a result of their exercise of magical healing
powers. In the early centuries of Western history Roman, Germanic, and
Christian sources all contributed to the notion of magical kingship: the Romans
had founded cults that elevated emperors to divinity, even in their lifetimes;
Germanic tribal rulers (or so it was believed) possessed powers over the crops
and the weather; and when Germanic kings converted to Christianity they began
associating themselves with the magical powers of that religion.
Early medieval kings could not rely on strong governmental institutions and
hereditary traditions to compel obedience from their subjects. They might only enjoy
success if they displayed “charismatic” powers, which they could if monarchy
assumed a “sacral” character.21 Thus the kings of the Franks began anointing them-
selves with holy oil in the seventh century; that custom was revived and strength-
ened in the ninth and tenth centuries in part because (according to Michel Rouche)
the Church, faced with widespread social disintegration in an especially chaotic age,
attempted to “stem the tide of anarchy by enhancing the concept of kingship.”22
In those centuries the line between secular and religious powers claimed by kings
became blurred. Kings were regularly consecrated as a part of the ceremonies sur-
rounding their coronations. Were kings endowed with priestly powers? Medieval
kings certainly impressed their people with such powers: they took communion in
both kinds (wine was ordinarily reserved for the ordained clergy), and they gave
their armies signs of benediction. The pious Emperor Henry III (1039–1056) refused
to laugh at jests, because canon law denied such pleasures to ecclesiastics.23
And aside from the confusions that might have arisen from theological prac-
tice, legends and popular beliefs surrounded monarchs and associated them with
magic power. Upon the death of Halfdan the Black of Norway, his body was
divided into four pieces and buried in different parts of the kingdom to ensure
good harvests.24 Emperor Otto I (936–975) rarely slept, or so a chronicler
impressed by his watchful care of his realm believed.25 True kings could always
be determined by an identifying royal birthmark, or by the fact that lions respect
royal blood; when in doubt about the true king, put the claimants in the lion’s
den and acclaim the survivor. Old children’s stories such as “The Princess and
the Pea” make the same point: royal blood is qualitatively different.
Medieval Diseases and Responses 31

All Western medieval kings were surrounded by some measure of these con-
cepts and powers. All pious kings also had a religious duty to be charitable to the
sick, and that obligation strengthened in the eleventh, twelfth, and thirteenth cen-
turies, as the ideals of the revived Western Church gained force. But some partic-
ularly saintly kings acquired reputations as healers, and their powers confirmed
their sanctity. Two early such examples were Robert II (“the Pious”) of France
(996–1031) and, Edward (“the Confessor”) of England (1042–1066); at such courts
there existed “a narrow line between ministering to the sick and healing them.”26
By the thirteenth century medieval kings—or at least some of them—had
acquired other bases of authority in addition to the charismatic. Their powers
might now be buttressed by judicial and financial bureaucracy; with such institu-
tional authority, kings might be revered because of their secular abilities as gov-
ernors. And institutional authority meant that a king’s powers might be less
dependent on his personal charismatic aura; just being the king was enough.
Thus the mystique of kingship may have been transmuted, but it persisted. In
two thirteenth-century courts it took quite specific thaumaturgic form: French
and English kings asserted their particular power over the disease called scrof-
ula, which was said to submit to the royal touch. This specific conviction grew
out of both political factors and a persistent belief in supernatural powers that
people—and especially kings—might manipulate. Scrofula is a disfiguring but
rarely fatal ailment that manifests itself as putrid blotches on the skin of the face
and neck. It is in fact a form of nonpulmonary tuberculosis that affects the lymph
nodes, especially those in the neck. We now understand that scrofula is subject
to frequent remissions, a fact that helps us understand the apparent success of
the royal cures of the later Middle Ages.
As we have seen, all medieval kings surrounded themselves with some meas-
ure of supernatural power, and as Western civilization became more settled (in
the period 1000–1200) kings deliberately associated themselves with ritual and
practice that separated them from their subjects and thus magnified their author-
ity. At the same time, however, the Western Church, and especially the papacy,
embarked on a major assertive program of its own, denying sacramental and
supernatural powers to lay authority and asserting that only the Church could
intervene with divine will. In part the claims of the French and English kings to
cure scrofula were political responses to papal “aggression,” but the boundary
between two other motives—a genuine belief in godlike powers and a cynical
manipulation of credulous subjects—was not a clear one.
Marc Bloch, the French medieval historian, claimed (in Le roi thaumaturge,
originally published in 1924) that the specific royal touch for scrofula began with
Philip I of France (1060–1108) and Henry I of England (1100–1135), and he
advanced plausible political reasons why that may have been so.27 More recently,
however, Frank Barlow has argued that available sources support such a specific
32 The Burdens of Disease

association of royal powers and scrofula only in the late thirteenth century;
before that time “royal sickness” expressed a broad category of disease identi-
fied not so much by symptoms as by a king’s power over them.28 It is possible
that the specific claims about scrofula emerged from a process of trial and error
with such maladies, as scrofula’s self-remitting character seemed to confirm
royal powers. Barlow believes that Louis IX of France (1226–1270), a particularly
saintly monarch, may have initiated the touch for scrofula, and that the first clear
French documents about the practice come from the reign of Philip IV
(1285–1314). In England Henry III (1216–1272) probably started the touch, in
imitation of Louis IX, and again clear documentation comes from his successor,
Edward I (1272–1307). Although Barlow has convincingly revised Bloch’s
chronology, something of Bloch’s original political argument stands, or at least
may be applied to Barlow’s thirteenth-century situation. Bloch noted that both
Philip I and Henry I represented dynasties that might have been seen as
usurpers, and the possession of supernatural powers of healing would obviously
bolster their claims to legitimacy. God had sanctioned their rule. In the thirteenth
century Henry III of England may have undertaken the practice of healing and
thus “reconfirmed the monarchy after the disasters it had suffered since 1215,”
which included King John’s surrender to his aristocracy in the Magna Carta.29
Philip IV of France became embroiled in a tremendous struggle against the
assertions of the papacy, a struggle that culminated in Philip’s inspiration of
a physical assault on Pope Boniface VIII; his use of the royal touch for scrofula
may clearly have had a political purpose, for his political theorists argued
vigorously against the upholders of the papal doctrine that royal miracles were
Touching for scrofula quickly became a ritual in both courts. The king laid his
hands on the sufferer’s afflicted parts, signed with the cross, and washed his
hands in water that was then thought to have some healing power of its own.
A coin was sometimes presented to the sufferer; the coin too might confer con-
tinuing therapeutic power, and receipt of it certainly helps explain the popularity
of the rite. In the fourteenth century the English kings touched upward of five
hundred of the afflicted per year: in France people came from all over that exten-
sive realm to be touched. Sufferers from other parts of Europe journeyed to
England or France to benefit from the touch. Further, both the French and the
English monarchies experienced political crises in the fourteenth and fifteenth
centuries, and times of dynastic instability or royal weakness brought more insis-
tence on the power of the thaumaturgic king. One of the most vigorous propo-
nents of the royal touch was Edward II of England (1307–1327), a generally
unsuccessful king who was eventually murdered by his aristocracy. In order to
shore up his crumbling power and prestige Edward II invented a legend of holy
oil, and not only touched for scrofula but distributed rings that protected their
Medieval Diseases and Responses 33

wearers from epilepsy. Edward claimed that the miraculous powers inhered in
his person, not in God’s presence at the altar where the rites were performed.
So the healing touch was a product of political motives, at least in part. But it
coincided with a widespread belief in kings as magicians, endowed with near-
divine powers, and that in turn formed part of a more general belief in what Bloch
called “a whole magical outlook on the universe.” Magic played a large role in
Europe in the Middle Ages, and not just then. We shall see repeated examples of
its role in healing, especially in Chapter Five. Faith in supernatural powers per-
sisted for centuries, and for some it persists still. But the royal touch for scrofula
fell into discredit in part because many people stopped believing in what Bloch
terms “the supernatural and the arbitrary.” When the supernatural and the
arbitrary came under heavy theoretical fire in the seventeenth and eighteenth
centuries, the royal touch simultaneously lost credit.
Just as political factors partly accounted for the rise of the royal touch, so too
did they figure in its demise. The division of Western Christianity that followed
the Reformation had some political effect, for Catholics came to doubt the heal-
ing powers of the Protestant English kings and Protestants similarly doubted the
Catholic French rulers. Internal religious divisions in both kingdoms led parti-
sans to question the touch. Nevertheless Charles II of England (1660–1685)
touched thousands; so too did James II (1685–1688), but in his reign the rite lost
credibility because he blatantly associated it with his unpopular Catholicism. His
successor William III (1688–1702) did not believe in the touch, and in any case
was not a proper king by inheritance. The Hanoverian dynasty that succeeded
after 1714 likewise had slim hereditary claims to such powers, and—unlike ear-
lier monarchs who used the ritual to bolster their legitimacy—drew its support
from parliamentary advisors determined to downplay such associations with
a sacerdotal monarchy. The exiled Stuart pretenders kept touching their
followers in the eighteenth century, to be satirized by both rationalist thinkers
and the political followers of their Hanoverian rivals. Meanwhile in France
Louis XIV (1643–1715) was a master of such rituals, but his successor
Louis XV (1715–1774) was not. Increasingly criticized by the thinkers of the
Enlightenment, the custom apparently died out under an Enlightenment king,
Louis XVI (1774–1792), only to be reborn, fittingly, in the reign of the self-
consciously medieval king Charles X (1824–1830), the last monarch in Western
history to touch for scrofula.

The Medieval Disease Environment

By 1300 medieval Western civilization had changed almost beyond
recognition from the poor, rural society that it had been four or five hundred
years earlier. Cities had grown both in size and importance. Locally based politi-
cal power, often of a very rough-and-ready sort, had given way to much more
34 The Burdens of Disease

elaborate and centralized authority, with relatively sophisticated bureaucratic,

taxing, and judicial machinery. An increasingly specialized economy of both rural
raw materials and urban crafts, traded across impressive distances, had replaced
local self-sufficiency. Arts and letters flourished in a culture that both recalled
the triumphs of ancient civilization and embroidered a rich religious tradition.
This advancing civilization certainly assisted the health of its population in
several generally important ways. Gradual agricultural change contributed to
important nutritional shifts. At the beginning of the common era northern and
western Europe was heavily forested and boggy, and some sections remained so
for centuries. The Germanic and Slavic peoples who settled those lands slowly
cleared and drained them, and gradually developed agricultural technology that
took advantage of the northern soil and climate. From the sixth century the heav-
ier plow, pulled by a larger team of animals (eventually including the powerful
horse) exploited the rich soils of the north, while the “three-field” system pro-
vided for two growing seasons per year in the wetter climate. The Western civi-
lization that emerged thus had the capability to grow more grain per acre than
its Greco-Roman predecessor, and could ultimately sustain a larger population.
By the eleventh century the agriculture of the West could supply more calo-
ries to its people, although in other respects nutrition may have suffered. The
northern diet that emerged in the years after the sixth century included more
meat and dairy products, so it may have been richer in calcium and protein. But
animal fats, especially butter, tended to replace vegetable oils, to the likely detri-
ment of European cardiovascular systems. Fruits in the north played a smaller
role than they did in the Mediterranean, and green vegetables were still few,
despite the cultivation of peas and beans. Vitamin-deficiency diseases remained
rampant: scurvy, rickets, beriberi, stunted growth, and eye trouble from lack of
vitamin A. Maldistribution of wealth put too much food—especially meat—in the
hands (and constipated digestions) of a few, and left the great majority heavily
dependent on grain. Dependence on grain meant dependence on the weather;
and although the period between about 700 and about 1200 was one of generally
favorable climate, without variety of crops the failure of one crop in one season,
whether from not enough rain or too much rain at the wrong time, meant physi-
cal hardship and hunger.
But despite these qualifications, improved agricultural technology and better
security for both farmers and trade routes sustained a growing population with bet-
ter nutrition—certainly more calories, and perhaps a greater variety of nutrients—
at least until the middle of the thirteenth century, and in some places well into the
fourteenth. The smoothly functioning Italian city-state of Siena still ate well into the
1340s. The stronger and surer hands of central political authority meant more than
simply safer trade routes. The security of life in general was improved between the
tenth century and the thirteenth, perhaps most notably for women. Our knowledge
Medieval Diseases and Responses 35

of medieval demographics is hampered by large lacunae in the evidence, but some

data suggest that men may have considerably outnumbered women in early
medieval centuries, perhaps because female infanticide was practiced and perhaps
because conditions of life—including the hazards of childbirth, random violence,
and a lesser share of scarce calories—bore more heavily on women.
In fact the centuries between roughly 400 and 1100 were unusually violent
ones, and the character of violence in them differed from that of succeeding peri-
ods. Local political authorities, whose power seldom extended beyond a day’s
ride, dominated life. With a settlement of relatively thin density, and relatively lit-
tle movement across distances, massive chains of infection were less likely; the
infrequency of movement, whether stimulated by violence or trade, meant rela-
tively little biological exchange. Too often, however, conditions approached polit-
ical anarchy. Where order was maintained at all, it was enforced by bands of
armed men who swore personal allegiance to the leader who promised to sup-
port and protect them. The lower orders remained almost entirely at the mercy
of these rapacious gangs; brute force maintained the peasantry in poverty,
a poverty whose inadequate nutrition opened the door for secondary infections
and whose daily realities meant living quarters shared with animals and hence
with microorganisms and disease vectors.
But in the “high Middle Ages,” between about 1100 and about 1300, political
power began to concentrate in fewer territorial hands, especially in western
Europe. Kings and other rulers of substantial territories began bringing the local
lords and their violent henchmen under control. A knight with his own landed
estate might be beholden to no one, but an armored soldier equipped and paid
by royal coin had less independence. To the extent that some twelfth- and
thirteenth-century kings were thus able to impose some form of “law” on their
armed retainers, those centuries were more peaceful ones.
Reinforcing royal efforts in those centuries were both a growing commercial
population that desired protection from piracy and brigandage and a powerful
institutional church that wished to rein in the casual violence. The Western
Church, from an increasingly strong political position, gradually persuaded bru-
tal lords and their followers that gentleness, especially with the relatively help-
less, might be a more effective key to the kingdom of heaven than violence.
Women were beginning to live longer than men, and their proportion of the pop-
ulation increased. The Church suggested another key as well: charity. An out-
pouring of philanthropy occurred in the high Middle Ages, a movement that
founded a vast number of institutions for the care of the sick and the poor.
However ineffective or corrupt such institutions might have been, their sheer
number is striking, as the figure of 19,000 leprosaria testifies.
A more formal medicine emerged in those centuries as well. Physicians
received a “professional” education in the universities, and this training brought
36 The Burdens of Disease

them into contact with (above all) the traditions of Galenic medicine, anatomy,
and physiology, often as mediated by Arabic authors. Physicians thus joined the
clerics and those learned in the law as the educated professionals, whose learn-
ing carried certification. And their formal medical practice was at least partially
based on tenets of human reason; supernatural explanations may have still pre-
dominated, but they might now be employed to explain final or ultimate causes,
not proximate ones.
Formal medicine’s impact was mixed, however. The numbers of practitioners
remained small; although modern scholars have identified a surprising number
of such physicians, I will argue in Chapter Five that for most medieval people
physicians were only a small part of a wide spectrum of healing alternatives.
Although Galenic medicine had many impressive features, it still lacked
satisfactory principles of either etiology or therapeutics; leprosy illustrated its
fundamental impotence, and plague, as we shall see in Chapter Three, would
overwhelm it. At the same time formal medicine began its long attack on other,
competing, forms of health care, attempting to drive out traditional folk healers
whose trial-and-error remedies might have had some validity.
The growth of cities and of trade was not an unmixed blessing for health, either.
Medieval cities became intensely crowded and intensely dirty. Medieval people
bathed because it gave them sensual pleasure, not because it made them “clean.”30
Provisions for fresh water and sewage removal fell considerably short of those of
the Romans. Vermin infested the population. And regardless of sanitation, or lack
of it, the mere crowding of the population in cities presented opportunities for some
diseases to spread. If the lack of sanitation meant high levels of intestinal infec-
tions—diarrhea, dysentery, typhoid fever—the crowds meant tuberculosis,
influenza, smallpox, measles, and (dramatically in 1347–1350) plague. Another
measure of “progress” intervened as well: the frequency and complexity of trade
and travel. By the late medieval and early modern centuries, as will be apparent in
Chapters Three and Four, Western civilization took part in what William McNeill
calls the sharing of disease pools. Plague spread rapidly through fourteenth-
century Europe; typhus and syphilis did the same in the sixteenth century,
although they might have already had an earlier foothold; smallpox rapidly moved
from Europe to the Americas. The European population grew prodigiously
between 1000 and 1250 in part because it could shelter within a still-isolated bio-
logical environment; its growth, and that of its “civilization,” ended that isolation.
Leprosy made clear some of medieval civilization’s limitations in the face of
disease, particularly its inadequate etiology and therapeutics, its association of
disease with the divine will, and its association of disease with the sins of individ-
uals and groups. The arrival of plague in the fourteenth century further illus-
trated those weaknesses, which were then paradoxically magnified by the
greater complexity and sophistication of an increasingly urban world.

The Great Plague Pandemic

T he most serious epidemic outbreak in Western history began in Sicily

in October 1347. Between that date and the end of 1353 most of Europe was
affected. The disease most likely responsible was the plague, apparently in both
its bubonic and its pneumonic forms. In the course of this massive epidemic
between 30 and 60 percent of Europe’s population died, a nearly inconceivable
human disaster. The event—much later and for unclear reasons called the Black
Death— had a profound impact on the imagination of the time, and has attracted
considerable historical attention in recent decades. What caused the epidemic?
Where did it come from? Where it go, and how did it spread? Was the Western
society of the 1340s ripe for such a catastrophe? What did medieval people make
of the epidemic? What did they do about it? What were its consequences? And
finally, why and when did plague cease its hold on the West? All these questions
have generated historical controversy and will repay careful review.

Plague is caused by a microorganism, Yersinia pestis (or as it was for-
merly known, Pasteurella pestis), parasitic in various burrowing rodents. The
microorganism is carried from rodent to rodent most frequently by fleas, which
bite infected rodents and then carry the bacteria to other rodents. Many rodents
may carry plague, including marmots, ground squirrels, and prairie dogs, but
the rodent most often involved with human epidemics has been the rat, and espe-
cially the so-called black rat (Rattus rattus), an adept climber that is particularly
at home in human dwellings. Plague may remain enzootic (that is, endemic
among animals) in a population of rodents for a long time. If it reaches epizootic
intensity (that is, becomes epidemic) the larger number of animal deaths will

38 The Burdens of Disease

increase the number of their accompanying fleas who will seek new hosts. Those
fleas may become vectors—carriers that convey an infectious agent from one
host to another. In the case of the black rat, the rat flea (Xenopsylla cheopis) is a
frequent vector, but other flea species may play a role, including (although this
is controversial) the human flea (Pulex irritans). The new host may—perhaps
only by chance—be a human.
When a flea transmits the microorganism to a human, the form of plague called
“bubonic” results, a disease that apparently depends on a continuing epizootic of
infected rodents during which humans inadvertently get in the path of a rodent-
flea-rodent transmission. Plague may, however, pass from one human to another.
Some authorities believe that the human flea, Pulex irritans, sometimes carries
Yersinia pestis bacilli between people, making the spread of bubonic plague possi-
ble without the constant necessity of an epizootic rodent reservoir. And all agree
that the pneumonic form of plague requires no vector. Pneumonic plague occurs
when Yersinia pestis settles in the lungs, and from there spreads by drops of saliva
into the respiratory tracts of others. Pneumonic plague was almost certainly an
important element in the great epidemic that began in 1347, but the fact that it is
almost invariably and rapidly fatal limits its power of diffusion, for its victims
perish before they travel far or contact many others.
Many questions persist about the identification of the microbe responsible for
the great “plague” of 1347–1353. Some of those questions focus on its apparent
epidemiology. How could an epidemic on the scale of the 1347–1353 events be
generated by accidental encounters with fleas that generally have little interest
in human hosts? How could the epidemic spread so rapidly across a subconti-
nent when it depended on populations of infected rodents that move from place
to place only very slowly? To drive so many fleas to seek human hosts, rats must
have died in immense numbers; why didn’t contemporaries notice an unusual
pile of dead rats? On the basis of such questions some biologists, epidemiolo-
gists, and historians have argued either that the disease of those years cannot
have been plague, or that (if it was plague) the generally accepted mortality fig-
ures must be highly exaggerated.1
Such arguments, however persuasive, fly in the face of considerable historical
documentation of both the extent of the disaster and the symptoms of the dis-
ease. Bubonic plague manifests itself most dramatically in “buboes,” the large,
hard, painful swellings in the groin, armpit, or neck that form when the infection
reaches the lymphatic system. Devastating symptoms rapidly ensue: a rapid rise
of body temperature, delirium for some and stupor for others, and progressive
failure of vital organs as the microbe reaches them. Death follows in three to five
days for about 60 percent of those infected. Death from pneumonic plague is
even more swift and certain, occurring in less than three days. Many contempo-
rary accounts of the Black Death and from subsequent later visitations of the
The Great Plague Pandemic 39

disease vividly describe these symptoms.2 While the meaning of fourteenth-

century testimony about disease (from authors whose mind-sets were quite
different from ours) is always open to interpretation, much contemporary evi-
dence supports a diagnosis of Yersinia pestis infection; the repeated references
to buboes are particularly persuasive.
Some of the epidemiological improbabilities posed by Yersinia pestis may be
overcome if: (1) we grant the importance of pneumonic plague as a massive killer
in some populous localities; (2) we consider the possible role of the human flea
(Pulex irritans) as a human-to-human vector; (3) we remember that while rats
may not move very far or very fast on their own, they frequently ride with human
travelers both by land and sea; (4) we similarly realize that fleas can carry plague
microbes for considerable times and distances, while living in grain, textiles, and
other goods; (5) and we argue that fourteenth-century witnesses didn’t record
the deaths of rats because they had no reason to think that fact important.
In addition, alternative explanations—anthrax, typhus, an unknown “hemor-
rhagic virus” or some other now unknown infection—have their own weak-
nesses. Difficulties have been raised with each; for instance, the patchy
distribution of the victims of the Black Death seems more consistent with an
insect-borne disease than with a airborne virus, and anthrax simply doesn’t pass
from person to person in any way.3 It may be that (as Ann Carmichael has
argued) the vast mortalities of 1347–1353 (and later) resulted from a number of
diseases acting in tandem, with plague their greatest but not sole killer.4
Could the causative organism of the Black Death be identified by molecular
biology? Procedures now allow the accurate sequencing of DNA from small
quantities of surviving soft tissue, and some such tissue has been recovered from
dental pulp. Results have to date been inconclusive, and hotly debated. At least
some samples from, for example, 1348 Montpellier seem to reveal the presence
of Yersinia pestis. But even if so, that would at most prove that some fourteenth-
century deaths were due to plague, not that millions were. On balance, it seems
that Yersinia pestis, for all its epidemiological uncertainty, remains the “least
lousiest” solution to the puzzle of the Black Death. It may not be conclusive, but
it is better than the alternatives.5
If Yersinia pestis was the chief culprit in the Black Death, then the ecologies
of rodents and fleas form important parts of the history of the pandemic. Fleas
are sensitive to climatic variations and flourish only within certain ranges of tem-
perature and humidity. Generally they find those conditions in summer months,
which may account for the particular severity of bubonic plague in the summers
of 1348 and 1349. But fleas may also find ideal conditions both within rodent bur-
rows and in human clothing and bedding, so that epizootics may persist year-
round in rodent colonies and risks may persist for humans in all seasons. In the
fourteenth century the dominant rat of Europe was Rattus rattus, or the black
40 The Burdens of Disease

rat, exceptionally companionable with humans and their dwellings; the charac-
teristic European materials of domestic construction—wood, wattle-and-daub,
and thatch—made comfortable homes for rats and fleas alike. And while
fourteenth-century Europe had some densely populated cities, where large num-
bers of people constituted a critical mass for infections, we should remember
that the great majority of the population was rural. For that reason an important
epidemiological consideration was the density of rat and flea populations, greater
(especially in proportion to the human population) in rural settlements. Rats
especially gathered around grain stocks and grain mills, whence human traffic
also moved. Plague therefore posed many dangers to rural communities, which
may have suffered as much or more than cities.6

The Path of the Black Death

The course of the 1347–1353 epidemic has been well authenticated,
although its point of origin remains uncertain. Various areas in central or western
Asia have been proposed, without any conclusive evidence. In any case, the dis-
ease spread across the Asian steppes in the 1330s and was then carried by ship
from the Crimea to Sicily in 1347. Alexandria and Constantinople also faced the
disease that autumn, and before the year’s end plague had gained footholds in
Italian ports (notably Pisa, Venice, and Genoa) as well as southern France
(Marseilles) and the coast of Dalmatia. After the end of 1347, plague spread across
Europe by both land and sea; thus it reached Florence (by land) and the Aragon
coast (by sea) in early 1348, much of the rest of Italy by that spring, and southern
France in the spring and summer. Northern Spain was also infected, in part from
Bordeaux by way of the sea. By late in the summer of 1348, plague had come by
sea to England’s south coast, Ireland’s east coast, and northern France, while it
gradually spread overland from Italy into southern Germany in the same year. In
the course of 1349, plague’s spread continued from the south and west into cen-
tral Germany and the Danube valley; into northern England and the rest of
Ireland; and by sea to western Scandinavia and some points on the Baltic coast.
By 1350 Scotland, Sweden, Denmark, and northern Germany had plague; in 1351,
eastern Baltic lands; and in 1352 and 1353 plague reached first western Russia
and Ukraine, and then Muscovy. The epidemic had therefore completed a clock-
wise circuit through Europe, from the Black Sea into the Mediterranean, then
from southern and western Europe into northern and eastern parts. The regions
first affected (the Crimea) and last affected (Muscovy) were not that far apart.
A few anomalous pockets of land remained relatively free of plague: the largest
of these was Bohemia and part of Poland, and some cities elsewhere escaped with
lower mortality, notably Milan, Nuremberg, Liège, and some towns of Flanders
and Brabant. Many different factors may have lain behind their comparative
immunity. Plague spread in its bubonic form in the summer months, when fleas
The Great Plague Pandemic 41

flourished in the air as well as in burrows and bedding; if bubonic plague appeared
in a town in the spring or early summer, its epizootic reservoir in the local rodent
community might be exhausted in a few months and the rate of infection of humans
might then rapidly decline. Such a pattern repeated itself in many European towns,
which suffered three months of devastating bubonic plague and then relief. But if
bubonic plague only began in the late summer, a town might then face the horror
of pneumonic plague in the fall and winter, as plague intersected with pneumonia
and other respiratory ailments that flourished in cold, damp climates and spread
through populations confined indoors. So differential mortalities may have
depended on the timing of the plague’s arrival. And—as we shall see—human
actions may have moderated the plague’s impact on some towns.

Europe before the Black Death

This great epidemic made its way across a Europe whose social and eco-
nomic stability, and the very health of its inhabitants, had been weakening in the
earlier years of the fourteenth century. When we consider plague as an agent of
social change, that weakness must be kept in mind. Not all the disasters of the
fourteenth century can be ascribed to the epidemic, and the preplague condition
of the society helps explain the epidemic’s course.
Europe’s population perhaps doubled between 1000 and 1300, driven in part
by the agricultural technology discussed in Chapter Two. But by the end of that
time, and perhaps even before 1300, the society’s ability to produce food may
have reached an upper limit for the available technology. Growing cities, for
example, had become increasingly dependent on food supplies imported from
greater and greater distances; their vulnerability to famine increased accord-
ingly, for too many fragile links existed in the medieval transportation chains
that brought food to cities. New lands pressed into cultivation in the thirteenth
century were often marginal ones, whose productivity—never good—could fall
quickly. Soil erosion became more and more serious. David Herlihy’s studies of
the Italian town of Pistoia between 1240 and 1350 illustrate that by the beginning
of that period the area was already badly overcrowded, and that during the sub-
sequent century the population declined, as social and economic factors that dis-
couraged population growth accumulated in Pistoia.7 Certainly Pistoia was not
alone in suffering repeated bad crops and famines in the years before 1348. The
years from 1315 to 1317 were perhaps the most serious famine time in European
medieval history, begun by two seasons of heavy rainfall and cold temperatures
in 1314–15; by 1316 grain stocks in many places were exhausted. In five months
in 1316 the Flemish town of Ypres lost 10 percent of its population.
How important was lack of adequate calories for the spread of an epidemic
such as plague? In some broad sense it can be argued—as Robert Malthus did
and as more recently Thomas McKeown has done—that inadequate food supply
42 The Burdens of Disease

has worked together with unrestrained human fertility to hold human popula-
tions in a grip of scarcity, one that has only relented in the last two hundred years
in the West.8 In this view inadequate nutrition causes high levels of mortality,
above all because the poorly nourished more easily fall prey to infections. Against
this attractive hypothesis some difficulties have, however, been raised. It is not
clear that infections do prey more easily on the poorly nourished. Microorganisms
need a certain level of nourishment too, and the cells and tissues of the starving
may not provide it. Infections may develop more successfully in hosts who are
only slightly malnourished, not severely so.9 Some infectious epidemics illus-
trate that victims may be the healthy and well-fed; the great influenza pandemic
of 1918–19 resulted in particularly high mortalities for healthy young adults.
Plague’s incidence may have had little relation to the nutritional health of its
victims. What may have been more important, Ann Carmichael argues, is that
“secondary infections”—pneumonia piling on top of a primary infection such as
plague or influenza—struck poorly nourished people who were more quickly
weakened by the simultaneous assault of several microbes.
But other consequences followed such episodes as the 1315–1317 famines.
Extended periods of malnutrition weakened the population, perhaps had a
depressing effect on the birth rate (if only for psychological reasons), and
certainly increased infant mortality, which in turn changed the later age struc-
ture of the population in a way that adversely affected productivity. Witnesses
testified to increased geographical mobility, as the hungry repaired to cities and
monasteries that might have grain stocks. Their departure removed field hands
and thus further weakened agricultural output. Such rural migration also broke
down the isolation of villages, promoting the possible spread of contagious dis-
ease. The preplague world in Europe was one in which food was scarce and
hence expensive, land was in short supply and hence also expensive, and labor,
being plentiful, was cheap. But the evidence (from Pistoia, for example) suggests
that the overpopulated world of 1300 was already losing people before the great
epidemic, so that while the plague may have exaggerated changes, it did not
initiate them.

Medieval Opinions
What did medieval people make of this epidemic? In their view, what
caused it? For most of those who thought about that question, divine wrath pro-
vided the most satisfactory general answer. Other causes were often cited, but
for most writers such other reasons were “secondary,” explaining how plague
came in a particular time or place. Only God’s wrath could explain such a com-
prehensive disaster. Furthermore, God’s anger did not in this case fall on partic-
ular sinners, as was the case with leprosy. The scale of the plague suggested
rather that the whole civilization, or the whole human race, was being punished.
The Great Plague Pandemic 43

The general social and economic hardships of the previous hundred years gave
such arguments credence: man had sinned, the judgment of God was at hand.
Millenarian expectations were close to the surface already; they had emerged in
Italy around 1260, and the great epidemic would call them forth again.
Within the general framework of a heaven-sent scourge, medieval thinkers
offered a number of more immediate causes, and on the basis of those causes
proposed (or put into effect) some remedies. At the head of the list of such imme-
diate causes was “bad air,” the official doctrine of the medical faculties of some
universities, where it was integrated with Galenic theory. Hot, moist air, putri-
fied (ultimately by God’s action, to be sure), entered the lungs and caused a
blood disorder. Plague resulted. But if widespread agreement existed on the role
of bad air, great disagreement ensued about the source of that air. Some found
its origins in the heavens; thus the Sorbonne cited an unfortunate conjunction
of the planets that engendered bad air. Eclipses, always regarded as grave
astronomical events, were another possibility. Comets—sublunary phenomena
in the dominant Ptolemaic astronomy—were likely disturbers of sublunary air.
For some the moon influenced the stages of the plague, as it seemed to affect
other periodic human physical events such as menstruation. Others maintained
that “plutonic,” not astronomical, forces produced bad air: corruption poured
from openings in the earth such as volcanoes. Sicily, with both Mount Etna and
early cases of plague, was especially suspect. Or perhaps the bad air merely
accompanied a variety of natural cataclysms; the Sorbonne instanced earth-
quakes as “provoking an unaccountable abundance of frogs and reptiles.”10 Bad
air as well as frogs might result from such disturbances.
But for many medieval people such causal explanations were too “natural”;
they preferred to see supernatural beings: angels or demons, the small blue
flame in the sky seen in Düsseldorf in 1348, the witchlike apparition called “la
Mère Peste” or “l’Ulcéreuse.”11 With explanations such as these we enter a
murky area between environmental and contagionist explanations of disease.
Does God send the small blue flame to pass plague from one individual to
another (contagion), or to infect the entire atmosphere (environmental)? When
individuals (“l’Ulcéreuse”) were specified in the transmission process, contagion
was close at hand, despite the universities and their bad air. Certainly European
cities and people reacted almost instinctively as though they accepted contagion-
ism. In 1347 Catanians attempted, without success, to keep those fleeing Messina
out of Catania, and in 1348–1350 their efforts at quarantine were many times
repeated all over Europe. In fact European thinking about the plague did not fall
into clear categories of “contagionism” or “environmental cause.” Europeans
accepted God’s power as the primary cause and saw that power working in many
ways. Bedeviled by guilt, they saw humankind as a whole as provoking divine
wrath; perhaps reacting in fear and denying their individual guilt, they blamed
44 The Burdens of Disease

other individuals, either because those people had sinned or because they mali-
ciously and deliberately spread disease. Lepers and Jews, both groups outside
the framework of Christian society, were likely candidates for such accusations.
So too were domestic animals.
Part of the pattern of causal explanation involved not just God’s mechanism
(bad air, bad individuals, bad animals), but also the victim’s propensity for the
disease. It was perhaps not satisfying enough to say simply that God was scourg-
ing the human race; had some individuals made themselves susceptible by their
actions or their temperaments? Galenic theory generally viewed plague as a
blood disorder, and some physical types seemed prone to diseases related to
that humor: fat, florid people, and the sensually hot-blooded, especially women.
As in the case of leprosy, the fornicator was a likely victim, perhaps as a sinner
who displeased God, perhaps as a fool who sapped his strength; for men espe-
cially, sex was thought to weaken the constitution. Some thought revolved
around questions of age, social class, or profession. The rich—especially the
very rich and powerful—seemed less susceptible; physicians, surgeons, apothe-
caries, and members of religious orders were thought vulnerable. Others
believed in a “natural predisposition,” or a hereditary propensity for the disease,
consistent with some Hippocratic traditions.
Out of these varying theories of cause—operating within the grand general
cause of God’s wrath—came medieval responses and remedies. The scale of the
disaster was quickly appreciated and gave rise to widespread panic and flight, the
latter of course easier for the rich than for the poor. Omens were consulted. Belief
in God’s anger led to numerous local attempts to propitiate the divine rage. Town
after town held religious ceremonies and processions. Cities resolved to build
new churches. Legislation attempted to enforce a purer morality on the populace,
as in Siena where the city government outlawed gambling in an attempt to win
divine favor, or in Tournai where swearing was forbidden and cohabiting couples
were ordered to marry. In some dramatic cases groups of individuals took on
themselves the sins of society and hoped by their suffering to assuage God’s
anger. That response was most vivid in the processions of the Flagellants that
moved through the towns of Germany and the Netherlands. The Flagellants were
among the most striking manifestations of medieval millenarianism; they came to
see themselves as armies of saints whose very blood had redemptive power, as
they not only assumed the burden of humanity’s sins, but through their suffering
(in their self-flagellation) assumed Jesus’ role as redeemer.
But the plague came anyway. Probably the gathering of city populations in
processions and religious ceremonies offered more opportunities for contagion,
as would the enthusiastic war bond rallies in the midst of the World War I
influenza epidemic. Many responses were based on a more “natural” explanation
of the disease’s cause. Many people believed in some type of contagion, regardless
The Great Plague Pandemic 45

of official “bad air” environmentalist doctrine. Port cities refused to allow ships
with plague victims to land. Pistoia imposed quarantines on the movement of
people and goods. Bodies of the victims were shunned, thrown over town walls,
hastily buried in mass graves while their clothes were burnt. Dogs and cats, pos-
sible bearers of contagion, were massacred, allowing the rats more license. Belief
in bad air led some to flee to the pure mountains; an extreme (and well-known)
example of a search for good air was afforded by Pope Clement VI, who barri-
caded himself, surrounded by fires, in his palace in Avignon. He survived.
Measures of public health—quarantines, burning the clothes of the sick, dispos-
ing of bodies outside town walls—might also be the outcome of a “bad air”
theory, if clothes or bodies were thought to produce the corruption.

Immediate Effects
The immediate effects of the plague on communities varied, although
mortality was high in most places affected by the disease. Studies of particular
places in the midst of the epidemic leave different impressions. In some places
the fabric of the social order seems to have been surprisingly resilient; after a few
months’ interruption, city government resumed its functions, men of the profes-
sions went about their business, and social order was consistently maintained. In
other cases communities embarked on frenzied searches for scapegoats, and
grave social revolution threatened. Almost all communities apparently ground to
a halt for a few months. Thus Siena’s economic and political activity largely ceased
in June, July, and August 1348: the woolen cloth industry stopped working, olive
oil imports ceased, and the city’s courts recessed, while the government ordered
religious processions and ended legalized gambling. Fields in the surrounding
countryside were neglected, animals wandered uncared-for, and mills closed.
From Perpignan in April, May, and June 1348 the only legal documents that
survive are wills; other legal or political business apparently simply stopped.
Modern historical studies of Siena, Perpignan, Pistoia, and Orvieto all sug-
gest that after a few months political and legal machinery once again functioned,
and that at least in some cases city governments tried to assist their populations
in coping with the disaster. In Perpignan the persistence of will-making even at
the height of the epidemic was impressive; a will written by professionals, with
witnesses, was a “fairly sophisticated document, representing a rather high level
of social organization” that did not break down in panic.12 When the worst
months passed, legal documents reappeared in full flower, and their character
reveals a community rebuilding itself: there were again estate settlements, dis-
putes among heirs, restorations of dowries, and apprenticeship contracts as new
workers were recruited to fill gaps in trades. The finances of the city govern-
ment of Siena recovered rapidly, as the governing council successfully raised
taxes and imposed forced loans, all of which met the higher demands of the city’s
46 The Burdens of Disease

mercenary army. Individuals who had fled the city began returning, and the city
government attempted to assist the reconstruction of the rural hinterland
of Siena: taxation of hard-hit villages was remitted and rent payments were
canceled. A city government that could actually boast of a budget in balance, as
Siena could do in 1353, was hardly a demoralized or disorganized community;
a balanced government budget in Siena, according to William Bowsky, rarely
happened even in prosperous times.13 The government of Orvieto was perhaps
less effective than that of Siena, but there too the council resumed its regular
meetings and appointed new city employees.14
Similarly mixed evidence comes from rural communities in England, where
several locales have been studied. In some respects agricultural activity, like its
urban counterpart, came to a near halt during the three or four months in which
plague peaked. Many landholdings were vacated by either the death or the flight of
the tenants; mills fell into disuse, buildings deteriorated, and livestock wandered
unsupervised. Rural societies might depend heavily on the management skills of
a bailiff or other agent; a very high turnover of management positions occurred
in the manors of Cuxham, near Oxford, between 1349 and 1359.15 A cleric’s death
might also unhinge a village, and many English studies document the high mor-
tality of the clergy.16 Yet in Midlands manorial society, legal procedures and their
routines were maintained (as they were in Perpignan), even though those proce-
dures for a time concentrated almost wholly on the registration of deaths, con-
veyances of vacant holdings, and wardships arising from the great epidemic.17
But while communities showed considerable resilience in the face of human
calamity, social and political systems did suffer shocks that manifested them-
selves in later years. Siena provides a good illustration. The epidemic apparently
furthered a considerable social and economic upheaval there, involving newly
emerging rich and newly created poor. The new rich showed their political power
by ending monopolies enjoyed over tax-farming by a narrow circle of bankers.
The city government, alarmed by the new rich and their ways, passed sumptuary
legislation to limit their fancy-dress display. While new wealth vied with an estab-
lished oligarchy, new citizens flocked into the city, encouraged by the govern-
ment’s immigration policies. Political tensions between these groups intensified,
and the existing government (the Council of the IX) was unable to defuse them.
In 1355 a revolution overthrew the IX, thus ending seventy years of continuous
oligarchic domination. In Bowsky’s view the great epidemic served not so much
as the immediate disrupter of society as the catalyst that set in train or acceler-
ated larger social and economic effects.

Long-Term Effects
When we extend the question of effects over the balance of the four-
teenth century and into the fifteenth, more complications arise. How rapidly did
The Great Plague Pandemic 47

the population of Europe recover its pre-1300 level? Did the depression in
population have major effects on wages, prices, land tenures? Did productive
processes or land uses change? Were authorities—ecclesiastical, political,
intellectual—called into question? Clear answers to all those questions are diffi-
cult, but the great epidemic certainly had some weight in all such issues.
First, the Black Death of 1347–1353 seriously reduced the population of
Europe. Mortality may have ranged from 30 to 60 percent, in some places
higher, in some places lower. But the plague’s impact on the European popula-
tion did not end in 1353. Although controversy continues about just when the
population began to grow again, much local evidence suggests that repeated vis-
itations of plague in the years after 1353 contributed to holding populations down.
The population of Cuxham in 1377 had reached only one-third of its 1348 level.18
Many writers, in fact, see no real recovery of growth in the European population
until the end of the fifteenth century. For this remarkable period of declining or
stagnant populations the plague bears at least some responsibility. Once plague
established itself in the 1340s it remained an almost constant menace for over
three hundred years, in what may be properly called a prolonged plague pan-
demic. Jean-Noël Biraben has compiled tables which claim that plague was pres-
ent somewhere in Europe every year between 1347 and 1670.19 The most serious
and widespread episodes followed on the heels of the great Black Death; thus
the epidemics of the early 1360s and middle 1370s, though overshadowed by the
1347–1353 catastrophe, rank as demographic disasters in their own right. Such
massive after-shocks hampered the recovery of population levels late in the
fourteenth century; and although the intervals between major plague waves
seemed to have lengthened in the fifteenth and sixteenth centuries, the disease
could still be a powerful brake on growth in some localities.
The social and economic consequences of the great decline in population
between the mid-fourteenth and the late fifteenth centuries have been much dis-
cussed, and some points remain controversial. As we have seen, Europe in the
early 1300s manifested many signs of a society with cheap labor and expensive
land. To some extent the Black Death reversed that picture; Europe, now
population-short, experienced rising labor costs and falling land costs. Especially
in western Europe, the drastic depopulation forced landlords to lower rents, to
replace fixed-term rents with share-cropping arrangements, to offer higher
wages for agricultural labor, and to commute the traditional labor services
demanded of peasants by lords. Considerable regional variation in such effects
could be found; in some cases, for example, deaths among the tenantry enabled
landlords to let out lands on new terms that freed them from long-term custom-
ary arrangements favorable to a tenant family.20 But in many places in western
Europe the lives of peasants improved as the obligations of manorialism fell
away. Emmanuel LeRoy Ladurie’s classic study of the peasants of Languedoc
48 The Burdens of Disease

shows them enjoying the results of abundant and cheap land and high wages in
the second half of the fourteenth century and the fifteeenth century.21
For many European landowners the serious depopulation of 1347–1353 cre-
ated problems: lower rent receipts, a shortage of tenants, perhaps higher wages
to pay, perhaps lower prices for the produce of their lands as demand for those
products fell. Landlords had several options. They could join employers every-
where in attempts to hold wages down by statutes that could be enforced with
state power, or to use other legislative or judicial means to control labor (such as
restricting the laborers’ geographical mobility). Several European states adopted
such measures in the years after 1348—for example, the English Statute of
Labourers of 1349—and serious social and political grievances often resulted.
Another possibility for the landowner was greater efficiency. Labor apparently
became more productive, if only because (in agriculture) it was possible to aban-
don the cultivation of marginal lands and concentrate on richer soils. Still other
landlords converted their fields from arable to pasture and thus reduced their
labor costs. That point relates to a subtle but significant shift: that in the years
after the great epidemic, what we may loosely call “luxury” products and crops
prospered, at least in relation to more “staple” items.22 Several likely factors com-
bined to cause this trend. Survivors of the Black Death possessed greater per
capita wealth than they enjoyed before 1348, for such sources of wealth as land,
tools, or plate did not vanish in the same proportion as the people who shared
them. Survivors also perhaps enjoyed marginally higher incomes, if land costs
fell while wages rose. With both greater wealth and greater income came mar-
ginally higher disposable income, and items that had been unimaginable luxu-
ries might become desirable possibilities.
Producers—large and small—might respond to this new situation. The
demand for grain products fell with the fall in population; half the population will
not eat twice the bread it had eaten even if the price falls in half (that is, the
demand for such “necessities” as bread is relatively inelastic, or constant regard-
less of price). The years after 1348 were therefore difficult for producers of grain,
caught between higher labor costs and declining absolute demand for their prod-
ucts. For some, the answer lay in the production of goods for which demand
might be more elastic, goods that appealed to the new wealth and higher level of
disposable income. And so in Spain and England the importance of pasture for
wool increased. More land, proportionally, was also given over to crops from
which drink could be made: barley for beer in England and Germany, grapes for
wine in France, northern Italy, and southern Germany. More varied fruits and
vegetables appeared, especially in France and Spain, while the demand grew for
exotic substances such as sugar. Crops from which industrial materials came
prospered: dyestuffs, flax and hemp, mulberry trees (for silkworms). Meanwhile,
areas that had lived by the export of grain, such as Sicily and southern Italy,
The Great Plague Pandemic 49

suffered hard times. Finally, the position of smallholding peasants in this

changed market might be mixed; as subsistence farmers they benefited from
lower land costs, but as producers for a market they might lose.
The Black Death and subsequent plague assaults may have eased the lives of
surviving peasants in western Europe, making their land cheaper, increasing
their wages, and decreasing the traditional labor services expected of them. But
the general experience of the peasantry of eastern Europe should make us wary
of the power of the plague as an overwhelming historical cause. At least in the-
ory the same change in the positions of laborers and landlords occurred there,
although it is possible that the plague’s incidence and hence mortality was lower
in eastern Europe. Perhaps more eastern peasants survived, but that point
remains speculative; certainly the position of the eastern landlords strengthened.
They seized opportunities that made the east increasingly the supplier of large-
scale agricultural products to the more developed western European economies.
A different political milieu made it possible for landowners to tighten the bonds
of serfdom on the large estates on which they pursued those profitable activities.
Disease and its resulting depopulation is clearly not the single determinant of
social, economic, and political change.
The industries of towns likewise found a different climate in the post-plague
era. Without doubt the great epidemic caused tremendous short-run disruption,
as the social mechanisms of markets, transportation, money institutions, and pro-
duction collapsed in varying degree; a sudden dearth of artisans, or merchants, or
seamen might each bring their trade to a standstill, with effects that rippled
through an entire local economy. In the somewhat longer term, urban industries
shared some—but not all—of the circumstances that affected the rural economy.
A peasant in the countryside could benefit immediately from more or better land
after 1348; an urban artisan did not have those advantages. Productivity of urban
crafts may have declined per capita, at least temporarily, owing to the loss of hard-
to-replace skills. But some evidence suggests that such a decline was very tempo-
rary, and that both productivity and prices rose in the years after 1350. For that
prosperity both demand for manufactured goods and greater efficiency of produc-
tion may have been responsible. The same factors that promoted the sale of
“luxury” agricultural products also applied to manufactures; with more disposable
income, consumers demanded more clothing (or fancier clothing, involving silks
and dyestuffs) and the products of skilled artisans. Not all manufacturers prof-
ited; wool cloth made in Florence declined relative to the luxurious silk, and hard
times for some artisans (also facing competition from wool producers elsewhere)
resulted. Certainly contemporary observers noticed that conspicuous consump-
tion was a common reaction among survivors of the Black Death.
In the century after the great epidemic, Europe embarked on one of its seminal
periods of technological innovation. The sternpost rudder and the ship outfitted
50 The Burdens of Disease

with both square-rigged and lateen sails expanded the possibilities of ocean nav-
igation, and Europeans simultaneously adopted compasses from Asian civiliza-
tions. By about 1450 the various technologies involved in printing by movable
type had been brought together. In the 1400s the use of firearms made headway;
what in the 1300s had been a battlefield curiosity became before the end of the
1400s a decisive weapon of war. These technological changes are dramatic and
well known, but others of great importance also appeared in the late 1300s and
the 1400s. Especially significant were the spinning wheel and the rapid spread of
such instruments of power as water- and windmills (especially the latter) in
industrial processes. In some manner we may see all of these technological
changes as “labor saving,” whether printing presses that save the labor of copy-
ists, mills that save the labor of fullers, or cannon that save the labor of battering-
ram carriers. Is it too much to wonder whether the scarcity of labor in the century
after 1350 encouraged such innovations?

Plague and the European Spirit

The great epidemic had serious consequences for “authority” in several
respects. The landed class had dominated European social, economic, and politi-
cal life for centuries. On balance in western Europe, the Black Death damaged
its economic position, especially in respect to the peasantry which it had
exploited for so long. Its power over the peasantry did not end in 1350, but in the
later medieval centuries its authority did gradually weaken. Many factors con-
tributed to that immense change in social relationships, including the changing
power of towns and trading wealth, the growing authority of central political lead-
ers such as kings, and the development of military technology that supplanted
the armored horseman. Although it would be foolish to claim that the Black
Death ended the power of the western European landed class, it would also be
foolish to assert the epidemic’s irrelevance.
The institutional authority of the Church received several blows. To the extent
that it depended on learned and administrative talents, it suffered. Such talents
and learning could not be quickly replaced, and the death of a parish priest, for
example, sometimes resulted in the rapid ordination of a replacement with little
training or vocation. Such a circumstance might worsen an already bad situation
if the deceased priest had shirked his pastoral duties while the plague raged.
Many did (as many did not), and contemporaries held the secular clergy up to
unfavorable comparison with the mendicants; some members of the clergy had
abandoned their flocks, and others had enriched themselves in the crisis. And
even if a clergyman remained devoted to his parish in its travail, his powerless-
ness was manifest; the extent to which members of the clergy commanded
respect because of their “superhuman” qualities was weakened by their inability
to stem the disease, and by their own vulnerability to it.
The Great Plague Pandemic 51

The epidemic touched off long-simmering resentments against the Church as

well as against other symbols of authority. The direction taken by the Flagellant
movement in Germany provides an illustration. Flagellant processions, especially
in Germany, quickly passed out of clerical hands and control. The Flagellants
were often highly organized groups, under the direction of a master—a
layperson—who heard confessions and imposed penances, thus seemingly
poaching on the preserves of the clergy. A millennium was thought to be at hand,
in which Christ (perhaps accompanied by the Emperor Frederick Barbarossa,
awakened from his mountain tomb) would come again, slay the priests who
oppressed the people, and take from the rich to give to the poor. Flagellants saw
themselves as armies of saints. In some horrific cases the coming of such an
army ignited savage massacres of the Jews, the most obvious outsiders who
might serve as scapegoats for the tragedy of the epidemic; thus the Jewish popu-
lations of Frankfurt, Mainz, Cologne, and Brussels were put to the sword as a
part of the mass hysteria. As Norman Cohn describes the episodes, their revolu-
tionary potential was very real, not only against the authority of the Church but
also against the wealthy and the entitled.23
These plague-inspired popular movements fed other, later fourteenth-century
currents. For while the epidemic may have weakened the institutional authority of
the Church, it did not diminish the piety of the population. Although “piety” is hard
to measure (as is “authority”), the same civilization that denounced the laxity of
the clergy left bequests to churches for prayers and buildings, went on pilgrim-
ages, and manifested signs of intense personal piety that found an outlet in such
movements of the laity as confraternities. By the late fourteenth and early fifteenth
centuries such expressions of lay piety boiled over in what the Church judged to
be heresy, as with the Lollards in England and the Hussites in Bohemia.
Did public morality decline during and after the epidemic? Some witnesses
claimed that the horror of the plague loosened the bonds of behavior. Boccaccio
reported: “Others . . . maintained that an infallible way of warding off this appalling
evil was to drink heavily, enjoy life to the full, go round singing and merry-making,
gratify all one’s cravings whenever the opportunity offered, and shrug the whole
thing off as one enormous joke. Moreover, they practiced what they preached to
the best of their ability.”24 But the same author also told of those who lived
abstemiously in the hope of avoiding plague, and it is possible as well that the
plague overstimulated moralists to find “sin” everywhere to explain the catastrophe.
The drastic mortality laid the basis for conspicuous consumption by the survivors,
nevertheless, and there were those who adopted a tonight-we-drink-for-tomorrow-
we-die attitude. And as we have seen, in some cases the social fabric was badly
torn by revolutionary movements and hysterical massacres of innocents.
As hard to measure as “piety,” “authority,” and “morality” is the notion of a
civilization obsessed with death and its images. Johan Huizinga, in a famous book
52 The Burdens of Disease

written in 1924, drew a memorable picture of a post-plague world of extreme con-

trasts, of silences and noises, a highly strung civilization quick to violence and
outward displays of emotion, one in which the smell of blood mixed with that of
roses.25 Millard Meiss, who studied Florentine and Sienese art in the wake of the
plague, showed that art grew more “religious” and “conservative,” perhaps from
a general desire for intense personal religious expression in painting, but per-
haps a reflection of the typical arriviste tastes of those enriched by the changed
Certainly much evidence says that Europeans reacted to the Black Death with
mingled guilt and fear: convinced that their sins had brought on God’s wrath,
fleeing in terror when and where they could, and savagely turning on scapegoats.
To many Europeans the Apocalypse seemed at hand. Michael Dols’s study of the
same epidemic’s effects on another civilization both offers interesting contrasts
and reinforces the view of European guilt and fear.27 Dols found that Mamluk
Egypt, where the mortality in 1348 rivaled that experienced in Europe, was
generally free of most of the hysterical reactions found in Europe. According to
Dols, differences in religious background and ideas account for the different
reactions. A plague epidemic (part of the first great plague pandemic, mentioned
in Chapter Two) had ravaged the Middle East in the earliest years of Islam,
so that the faith’s original writings discuss the plague specifically and with (for
Muslims) enormous authority.
Muslims regarded the plague as God’s gift, not his scourge—“a mercy and a
martyrdom” for the faithful. Flight was therefore wrong, for it was flight from
God and God’s will (although there was some theological disagreement about
that point, Dols admits). Because plague came directly from God, Muslim
thinkers more consistently held to a heaven-sent miasma as the immediate
cause; doctrines of “bad air” did not slide into ideas of contagion, as they did in
the Christian world. Hence Muslims did not turn on alien minorities who might
be blamed for contagion. More generally, the Muslim tradition lacked the
Christian emphasis on original sin, which lay behind both the guilt felt by
Christians and the punishment which Christians believed that someone deserved.
Mamluk Egypt, Dols argues, reacted with reverent resignation to the disaster of
the Black Death.
But Dols’s contrasts may be too sharp. Did Westerners characteristically react
with flight, guilt, and a search for scapegoats? Remember the speed with which
communities rebounded from the social and economic blows of the epidemic;
remember not just the wild Flagellant hysteria, but the legal routines of
Perpignan, the effective governments of Siena and Cornwall, the rising prices
and productivity of craftspeople, and the prosperity of surviving peasants.
Furthermore, millenarian traditions did not necessarily involve Flagellant
excesses and threats to the social fabric; on the contrary, Robert Lerner
The Great Plague Pandemic 53

observes, the traditions of chiliastic prophecy in the West provided a framework

of belief that enabled some men and women of 1348 to find comfort when faced
with the awful event of the Black Death.28 Nancy Siraisi reminds us of another
truth: that medieval Western civilization constantly lived with hardships and its
people were inured to disaster; Christian traditions of the transitory character of
earthly life gave them resiliency or at least some comfort.29

The Continuing Pandemic

The Black Death of 1347–1353 was the first and gravest episode of what
became a pandemic lasting over three centuries. In the succeeding centuries
plague both persistently disrupted Western civilization and stimulated responses
from people whose concepts of plague gradually shifted from the environmental
to the contagionist. These two subjects were in fact interrelated, for the accumu-
lated experience with the plague contributed to the shifts in etiological percep-
tions, and it is at least possible that human agency ultimately diverted plague.
The particular effects of the long-term pandemic still need much study. Some
large-scale generalizations have been made (of the sort discussed earlier in this
chapter) about the social and economic effects of the prolonged demographic
downturn between the fourteenth and late fifteenth centuries, in which the plague
is at least heavily implicated. Certain specific places and times have been sub-
jected to close study, but satisfactory generalizations may be difficult, especially
because most such studies concern only parts of England, France, and Italy. The
subject remains a fruitful field for hypotheses. Such giant periods of Western his-
tory as the Renaissance, the Protestant Reformation, and the “general crisis” of
the seventeenth century were all played out on a plague-infected stage. And what
may be an important point about the stage: even in the comprehensive disaster of
1347–1353, and much more thereafter, the visitations of plague had wide local
variations. Some regions and cities felt its effects more than did others, or felt
those effects at different times. Did Bohemia’s escape from the worst of 1347–1353
lay the basis for the remarkable period of Hussite political power in the early
1400s, when the Bohemians repeatedly defied German imperial authority and
laid waste sections of Germany itself? Did the plague epidemics that swept Italian
cities in the late sixteenth and early seventeenth centuries disrupt their
economies and thus contribute to the end of their centuries-old European eco-
nomic dominance? Did Milan’s comparatively light brush with plague in
1347–1353 aid its relative rise among Italian cities? Was Antwerp similarly favored
in the sixteenth century with respect to other towns in the Low Countries? A large
number of such attractive speculations suggest themselves.
It is possible to be more concrete about changes in European beliefs about dis-
ease. Scholarly concentration on Italy in the years after 1350 has introduced us to
the changing conceptions of the plague and to changing responses of political
54 The Burdens of Disease

authority. Between 1348 and the 1500s—at least in northern Italian cities—the
idea of plague as a contagion gained great force, and if governments were not yet
ready to deny that plague was God’s visitation, in practice they took more and more
measures designed to combat the spread of infections. Remarkable and intrusive
systems of public health developed, which in turn gave rise to basic questions
about the limits of state authority exercised in the name of the public good. In early
modern Italian cities the power of public health machinery clearly interfered with
both the freedoms of individuals and the traditions of social groups.
As we have already seen, the great 1347–1353 epidemic prompted some reac-
tions that seemed based on the idea of contagion. But most of the official med-
ical (and theological) opinion spoke of “bad air,” or “miasma,” as the immediate
cause of the disease and based most preventive measures on that assumption.
Even if the cause were universally bad air, perhaps it might be escaped through
vigorous actions. Sometimes—because there might be “secondary” causes of a
local origin to explain the bad air—a general cleansing of the environment might
be undertaken. Thus Venice, for example, appointed an ad hoc committee of
influential citizens to “preserve public health and avoid the corruption of the envi-
ronment.” In the course of repeated plague visitations in the fifteenth century,
such ad hoc committees multiplied and in some cases became standing boards.
From 1486 on in Venice, three noblemen were annually elected to a Commission
of Public Health, which in turn supervised the activities of subordinate local
boards in towns in Venetian territory. Florence adopted a similar course in 1527.
Milan, governed more despotically than either the Venetian or the Florentine
republics, followed stronger measures in the 1348 epidemic, and as early as 1437
the reigning duke appointed a standing “health commissioner.” A five-member
board replaced this officer in 1534, after which date all three of the large north-
ern Italian city-states had standing commissions. These boards were primarily
administrative, not medical, in both their duties and their composition, although
the Milanese board was to include two physicians among its members.30
Initially the chief task of these boards was the elimination of possible sources
of corruption of the air, a charge reflecting the general miasmatic theory prevalent
in 1347–1353. In fact the early boards, whether ad hoc or permanent, undertook
actions on a diffuse front, for (as we have seen) the number and variety of possible
“secondary” causes of plague was very large. So in their pursuit of corruption-
free air, commissioners inspected wine, fish, meat, and water supplies; they wor-
ried about sewage; they regulated burials, and decreed the destruction of the
clothing of the deceased.
But by the fifteenth century the members of health boards gradually began
acting on more clearly contagionist assumptions. Those assumptions led to more
direct interference with both individuals and groups. Occasions that brought
crowds together became suspect, and were thus objects of regulation: schools,
The Great Plague Pandemic 55

church services, and—especially—the very religious processions that so many

towns had sponsored to propitiate God’s wrath. The movements of the suspi-
ciously transitory classes—especially beggars, soldiers, and prostitutes—came
under scrutiny. Boards of health also, in their attempt to stay informed, began
recording the causes of death in their cities. These early censuses of death them-
selves contributed to changing conceptions of cause.
Doctrines of contagion led to two particularly important forms of public health
control, both clearly articulated and practiced in the fifteenth-century Italian city-
states: municipal quarantine and isolation of the victims. A health commission’s
declaration that plague was present in a city set in chain a complex series of
administrative and political measures whose goals were quarantine and isola-
tion. By the end of the fifteenth century the cities had introduced the “health
pass” as part of the quarantine process. Other cities would erect a cordon sani-
taire around themselves, stopping traffic on roads and demanding health passes
from travelers, or perhaps halting all people and goods at their borders entirely.
As Giulia Calvi’s microstudy of Florence in 1630 has illustrated, travelers could
be the subjects of zealous monitorial interest.31 (Of course such a cordon’s effec-
tiveness was limited, for the early modern state lacked the rapid transportation,
communication, and electrical detection gadgetry that a modern state could
employ; seventeenth-century Florence could not erect a Berlin Wall.)
Within the affected town, families of plague victims would be confined to their
houses, with the doors locked and barred from the outside; supplies were passed
in through windows, preferably above ground level. Objects used by the sick and
the deceased were seized and burnt; houses were disinfected, painted with vine-
gar and fumigated with sulphur. A pesthouse might be established wherein suf-
ferers would be immured. Ideally a city would have not only a pesthouse but a
convalescent house as well, for those recovering from their brush with plague. All
these measures could entail considerable civic expense. Extra staff had to be paid:
physicians, surgeons, inspectors, guards for the cordon, grave-diggers. Food had
to be provided for the isolated, and items destroyed might have to be replaced.
The sweeping powers assumed by the boards of health, and the measures
that they enacted, led to conflict with both vested interests and the traditional
cultures of the society. The clergy took offense at the suspension of divine serv-
ices and processions in the name of public health. The business community soon
found that a quarantine could cripple a city’s trade and industry. Isolating a sin-
gle victim’s house, especially in those times of essentially home-centered crafts
and industry, could cause loss that rippled through the city as raw or finished
materials were destroyed. Urban artisans, who might live close to the margin of
survival anyway, could face ruin if health officers proclaimed plague in the town:
trade would stop, workers might be confined to their homes, stocks of material
might be seized and burnt. And as Calvi has made clear, more than economic
56 The Burdens of Disease

loss loomed for the common people of a city. Accumulated belongings had impor-
tant cultural value as symbols of family continuity, and their destruction by the
all-powerful health bureaucracy stirred deep resentment.
Finding a suitable pesthouse could present a difficult political problem, for no
one wished his property to be so used. “Hospitals” in these centuries did not exist
as institutions specifically for the sick, and when plague was accepted as a conta-
gion, separate isolation houses were required. For that purpose the states seized
private property and thus alienated property owners. And for the designated vic-
tims and their families, forcible removal to the pesthouse was a horror that broke
the family’s cohesion and was often perceived—with reason—as a death sentence.
Small wonder then that the boards of health could be unpopular. Sometimes
this unpopularity boiled over into disorder, such as the Milanese board con-
fronted in 1630 when “[t]hey were execrated by the ignorant populace which lis-
tened to a few physicians who, caring little for the public health, kept saying that
there was no question of plague . . . Fed and imbued with such delusion, the pop-
ulace began to slander Tadino and Settala [members of the health board] and
when by accident they moved through the narrow streets of the popular quarters
they were vilified with foul and unseemly words, and they were even pelted with
stones.”32 Giulia Calvi found no riot in Florence in the same year, but she turned
up even more suggestive—and probably more common—popular reactions to
public health regulations. Many possibilities existed for corruption: surgeons
could be bribed to report plague as something else, grave-diggers could be
swayed to bury a body in the church rather than in the mass shallow plots set
aside for plague victims outside the walls, confiscators of condemned material
could overlook prized possessions, officials commissioned to lock up a house or
shop could forget to do so. These acts might be seen as corruption, but they
might also be acts of mediation between the bureaucracy and the traditional com-
munity whose property and values were under assault.33 In those ways the popu-
lace cushioned the blows directed at them. The health bureaucracy was clearly
and deeply unpopular, in part because its rules broke families and rode
roughshod over important customary beliefs (such as veneration of corpses),
but also in part because some bureaucrats seemed to take their powers as license
to loot for their own gain. Health officers not only took bribes but extorted them,
sometimes in property, sometimes in sexual favors. They accordingly met the
sullen resistance of deception and evasion.
Perhaps in the face of such resistance, whether overt as in 1630 Milan, or
more subtle and pervasive as in Calvi’s Florence, city governments gave the
health bureaucracy broad powers and made attacks on its officers a major crime.
As early as 1504 Venetian health officers were empowered to arrest people and
inflict torture on them, and Florence in 1630 resorted to torture almost routinely
to enforce its health ordinances. It was, in addition, important that the health
The Great Plague Pandemic 57

boards consist of, or at least include, men of wealth and rank in the community,
who might be able to overcome resistance to unpopular seizures of property by a
status to which others (especially lesser property owners) might defer.
The contagionist measures of governments, then, stimulated various levels of
political opposition. But in addition the health measures themselves were some-
times the products of political forces, and we should not understand them solely
as reactions to the pressure of epidemic disease. Measures of isolation and quar-
antine included an element of social control, and the actions of a state against
disease might occur in the larger context of a period of greater state economic
and social manipulation, as early modern governments assumed some paternal-
ist characteristics. And the actions of the states themselves sometimes con-
tributed to changing etiological views.
The last point emerges clearly from Ann Carmichael’s study of Florence in
the fourteenth and fifteenth centuries.34 As the Florentine government amassed
facts about the incidence of plague (both in time and particular place), it became
convinced by the disease’s patterns that it spread by contagion. But the govern-
ment also concluded that the poor (and especially their children) were the most
likely carriers and hence in most need of control—not an unwelcome message
to the property owners of the city, frightened as they were by such disorders as
the Ciompi uprising of 1378. In Carmichael’s perhaps-extreme view, the plague
may have been little more than a convenient excuse for the dominant classes of
Florence to exert social control. Her argument gives short shrift to the divisions
within the propertied classes themselves, but it also makes the interesting case
that while plague undoubtedly occurred in post-1348 epidemics, the death toll in
those episodes was swollen by other illnesses that were likely contagions in the
congested, poorer, quarters of the city.
Paul Slack’s study of the plague in Tudor and Stuart England provides some
support for Carmichael’s view, but Slack is more cautious.35 English governments
remained well behind the Italian cities and their aggressive policies. In part the
English reflected continuing doubts about the contagion theory of plague; even in
seventeenth-century Florence, etiological doctrines contained elements of “bad
air” or “universal corruption,” and the persistence of the custom of giving grave-
diggers the clothes of the deceased testifies to the popular weakness of contagion
concepts. Slack also explores the nuances of religious views, in which tensions
persisted between “providential” and “natural” explanations of plague, and shows
how those theological perspectives—somewhat curiously—reinforced some
social policies by the seventeenth century. For churchmen who emphasized the
power of divine providence, the tensions proved especially strong; on the one
hand, resistance to God’s will was futile, but on the other, the clergy of the state
(Anglican) church were obligated to support government measures, including
those meant to counter plague. Perhaps for such churchmen the answer lay in
58 The Burdens of Disease

viewing individual sin as at least a “secondary” cause of plague, a view that might
license state action against sinners. And English “natural” interpretations became
congruent with such a view; although the English lagged behind Carmichael’s
Florentines in reaching this conclusion, by the seventeenth century English opin-
ion saw plague as a disease of the poorer urban districts, a social problem associ-
ated with poverty and disorder. Religious and secular opinion thus agreed with
government attempts to (at first) strictly isolate plague victims, and then (slightly
later) quarantine borders and establish pesthouses. Etiological theory, morality,
and the desire for order thus neatly coincided.
Slack would also agree with Carmichael’s view that governments took conta-
gionist actions against plague for their own reasons, not necessarily connected
with plague itself. English royal government, he found, was more apt to take vig-
orous measures in periods of aggressive paternalism (or maternalism, in the
reign of Elizabeth I). And Slack usefully explores the differences between the
regulations and intentions of the central government, and the actual government
practice at the local level. In 1578 Elizabeth I’s government ordered the isolation
of plague victims in their households and provided for a system of local taxation
to fund measures against contagious disease. These orders received the support
of parliamentary statute in 1604, but when royal policy moved to favor the con-
struction of pesthouses, such expenditure remained a matter of local discretion,
as indeed the tax rate was levied locally. The orders of the town of Bridport
(Dorset), in 1638, clearly illustrate both the local direction plague policy might
take and the way in which fear of plague overlapped other worries: “to use all
good and lawful means to prevent the same Contagion & other mischiefs and
inconveniences that may ensue unto this town for want of constant warding,” the
town council ordered the provision of a night watch by six householders.36 What
the good householders were to do if they saw plague is not specified, but they
clearly might prevent the disorder of “other mischiefs and inconveniences.”
Government did not have an enviable task. To what extent did it respond to
the demands of the propertied for order? Carmichael and Calvi—and to a lesser
extent Slack—would say that in the face of plague, order was a great priority. By
the eighteenth and nineteenth centuries quarantines and isolations sparked
more disorder from the same lower ranks whom governments wished to control;
government public health policies in the time of cholera precipitated major riots
in some European cities, as we shall see in Chapter Seven. But Carlo Cipolla sees
a different problem for Renaissance and early modern Italian city-states, for the
interests of the propertied might conflict with antiplague measures. As Cipolla
puts it, health boards often faced painful conflicts between their “moral obliga-
tion to mankind” and “unspeakable economic losses” if they suspected or discov-
ered plague in their cities.37 Should they publicize the presence of plague, or
attempt to hush it up and thus preserve the commerce of the city? Cipolla
believes that “moral obligation” most often won out, if only because an outbreak
The Great Plague Pandemic 59

of plague was impossible to hide. Other cities and their health boards received
reports from ambassadors, after all. Were health officers urged on by “moral
obligation,” behind which lay fear of discovery, or by a desire to discipline the
turbulent lower orders?
The growing conviction of the contagious character of plague certainly led
governments to remarkably active public health policies. Did those policies have
an impact on the course of the great pandemic? For it was true that plague lost
something of its tremendous grip between 1347 and 1670, and after the latter
date it became infrequent in the West. By the sixteenth and seventeenth cen-
turies plague had ceased to be the “major demographic regulator” that it had
been in the fourteenth and fifteenth centuries in England, although the magni-
tude of its periodic assaults was still considerable.38 Plague carried off as many
as 100,000 Londoners in 1665, out of a total estimated population of 459,000.
Such an experience makes it clear that the bacillus had remained lethal over the
centuries; the plague evidently did not gradually fade away. Rather, it simply dis-
appeared. According to Biraben 1671 was the first year since 1346 when north-
ern and western parts of Europe were free of plague.39 Further outbreaks of the
disease occurred in Spain and Germany between 1678 and 1682; in Poland
between 1708 and 1710; in southern France, notably Marseilles, in 1720–21.
Thereafter plague in the Western world was confined to the Balkans and Russia,
with occasional minor outbreaks in southern Europe, until the next great pan-
demic began in the late nineteenth century.
The disappearance of plague remains one of the interesting unresolved ques-
tions of Western history. After seemingly recovering demographic momentum in
the sixteenth century, Western civilization’s population stagnated through much
of the seventeenth. It then began to rise—rather dramatically—sometime in the
first half of the eighteenth, and that population growth was sustained over most of
the Continent until the early twentieth. This population surge coincided with the
rise of Europe to world domination. Many factors (some to be considered in
Chapters Six and Eleven) contributed to that rise, and many factors lay behind
Europe’s demographic burst. But certainly the disappearance of the disease that
had been the chief epidemic killer for over three centuries must have helped.
Many theories have been advanced to account for plague’s retreat, and no
one theory is totally convincing. The number of possible variables is large, since
the disease involves humans, rodents, insects, and microorganisms and their
possible shifts in behavior or even genetic makeup. Perhaps the climate provided
discouraging conditions for fleas, for the period between about 1590 and about
1850 has been called the “Little Ice Age,” when European mean temperatures
probably reached their lowest points since the true Ice Age. But the first great
epidemic of 1347–1353 occurred during a similar, if less severe, climatic
downturn. Andrew Appleby has argued that rats developed greater immunity;
plague-carrying fleas are less likely to abandon living rats and thus accidentally
60 The Burdens of Disease

light on a human.40 Robert Sallares speculates that the periodicity of plague epi-
demics during the three centuries of the pandemic may have reflected popula-
tion cycles among rodent reservoirs, and he concludes that changing rodent
immunities may be the best answer to why the pandemic eventually disap-
peared.41 But as Slack has noticed, the disappearance of plague was extremely
patchy geographically.42 The last cases in Italy occurred in the 1650s, while
neighboring southern France was affected in the 1720s; plague struck Moscow in
the 1770s and persisted in the Balkans until the 1840s. Could rat immunity have
been so unevenly distributed?
Another opinion, given particularly wide currency by Karl Helleiner in the
Cambridge Economic History, credits a shift in the dominant rat species, as the
larger Rattus norvegicus ousted Rattus rattus.43 The theory notes that the former
species is less companionable with humans and lacks Rattus rattus’s skill as a
climber, so that it maintains a greater distance from human habitations and espe-
cially human roofs; thus the chain of rat-flea-human might be broken. But the
chronology of plague epidemics almost completely disproves this theory of a
shifting balance of rat power. Rattus norvegicus did not arrive in England (where
the plague last visited in 1665) until 1727, while it had been long established in
Moscow at the time of that city’s 1771 plague.44
Hardest of all to prove are possible changes in Yersinia pestis itself. It is now
believed that that bacillus is a member of a genus that includes other pathogens
“genetically almost identical” but with very different clinical effects.45 Further,
Yersinia pestis has apparently manifested itself in three different strains, or “bio-
vars.” Have some shifts occurred in the makeup of the organism that would
explain the pandemic’s disappearance? Aside from the molecular possibilities of
such a shift, historical circumstances cast doubt on it. London suffered a major
plague epidemic in 1665 and never saw plague again, yet when Yersinia pestis
resurfaced again in Asia in the late nineteenth century (see Chapter Nine) it was
still very virulent.
Did human actions inadvertently interfere with plague? If housing construc-
tion methods and materials changed, perhaps the result distanced humans from
rats and fleas. London suffered not only a serious plague epidemic in 1665 but a
major fire in 1666. After the fire much of the city was rebuilt with brick and tile,
which may have provided less happy homes for rodents than the previous wood
and thatched roofs. But how general was London’s experience? All across the
European world, plague disappeared more quickly than old housing materials.
Similarly, the general possibility of improved sanitation, on the surface an attrac-
tive hypothesis, falters from lack of clear correlations between sanitary changes
and the plague’s disappearance. Plague last visited Naples in 1656, yet Naples
became notorious as a supremely unsanitary city. Did European nutrition
improve in the late seventeenth and early eighteenth centuries? Perhaps for
The Great Plague Pandemic 61

some, but most likely for a wealthy minority by then not much affected by plague.
Longer-term nutritional improvements for many may have occurred, as
European diets were supplemented by new crops such as the potato and by
legumes in new crop rotations, but significant improvement for the masses was
surely very slow.
Conscious human action against plague presents another possibility, one that
Slack has argued strongly. Quarantines especially, he says, may have decisively
interfered with the intercity movement of plague.46 Cipolla cautiously concurs,
arguing that on balance the public health bureaucracies of the sixteenth and sev-
enteenth centuries did a good job.47 Both Slack and Cipolla admit that many of
the public health measures had little effect, and some were positively harmful.
The killing of dogs and cats, undertaken because of their supposed role as con-
tagious agents, continued into the seventeenth century and clearly allowed rats
to run riot. Household isolation of victims most often harmed their families, and
had little to do with the rat-dependent transmission of plague from house to
house. It may, as Cipolla notes, have slowed the frightening spread of the pneu-
monic plague that made the 1347–1350 epidemic so horrific. Although the value
of quarantines almost certainly was real, questions remain about their practical
efficiency. Appleby, noting that plague disappeared from Italy but flourished in
the Near East, doubts the effectiveness of Mediterranean quarantines as an
explanation of the contrasts.48
Many mysteries still surround the end of the great pandemic that stretched
from the fourteenth century into the eighteenth. Human agency may have
assisted, but the case remains far from proved. The vigorous measures of public
health were of course undertaken without any clear knowledge of the etiology of
plague, or indeed of any other disease. But they were undertaken out of a grow-
ing conviction that plague was “contagious,” and that a cause such as contagion
could be subject to human intervention. The Italian health commissioners were
surely pious Christians, but their actions anticipated Alexander Pope’s advice:

Know then thyself, presume not God to scan,

The proper study of mankind is man.

The health boards created precedents for an active role of the state in the name of
public health, and in doing so they raised questions about the state’s regulatory
powers that remain meaningful today. Their activity may reasonably be seen as
an aspect of the scientific revolution of the sixteenth and seventeenth centuries
(see Chapter Five), when a conviction in human powers over nature took root.
And when another great plague pandemic got under way late in the nineteenth
century, Western public health machinery began to employ a powerful new etio-
logical concept against it, thus strengthening the hand of regulation over individual

New Diseases and

Transatlantic Exchanges

I n its long history the human species has been both extremely mobile
and extremely isolated. This paradox has had several different consequences for
humanity’s relations with disease. Prehistoric humans fanned out widely from
their original central African homeland, across Europe and Asia; they apparently
reached the Americas and Australia over land bridges (or at least narrow, shal-
low sea passages) at times of significantly lower ocean levels. These vast move-
ments diffused the human genetic pool over the globe and may also have diffused
a common pool of parasitic microorganisms as well. But in subsequent millennia
geological changes separated different groups of people as the land bridges that
connected Asia with the Americas and Australia were re-submerged. Humans on
different continents, and their accompanying parasites, had a period of separate
At least in the great Eurasian land mass (including Africa), however, isolation
was never total. Human movement resulted in some interchange of the vast num-
ber of other organisms that accompanied it, some of those organisms more obvious
(because visible) than others. Perhaps assisted by human traffic, diseases endemic
to one area of the land mass might make their way to other regions, as did plague in
the fourteenth century. To at least some extent Eurasians shared McNeill’s
“disease pool” of common vectors, microorganisms, antigens, and antibodies. The
inhabitants of the Americas and Australia, as well as of a variety of oceanic islands,
did not share some of the elements of that pool. For several millennia they had been
out of contact with Eurasia, with the occasional exception illustrated by the voyages
of the Scandinavians to North America in the eleventh century.
That isolation came to an abrupt end in the late fifteenth and sixteenth cen-
turies with the voyages of Columbus and his successors. Those voyages not only

New Diseases and Transatlantic Exchanges 63

initiated the movement of a wide assortment of animals, insects, and parasitic

microorganisms; such transfer was solidified by the establishment of an imperial
hegemony over much American territory, in which European domination
ensured the uninterrupted movement of both people and their accompanying
flora and fauna. What those movements have meant for the history of disease
has generated considerable historical speculation, both about the export of dis-
ease to America from the Old World and about America’s returning the favor.
And while each of the several migrating diseases has inspired different historical
questions, the overall experience with diseases such as syphilis, typhus, and
smallpox strengthened the Western belief in the importance of contagion.
Because this book emphasizes Western civilization’s disease experiences, this
chapter will devote more attention to Europe. But the American civilizations
now came into contact with the Euro-African world, and disastrous disease
consequences for them ensued that deserve some discussion as well.

Newly Recognized Diseases in Europe

Late in the fifteenth century several diseases appeared in Europe that
(at least apparently) had not previously affected Western peoples. The most
prominent of these ailments were what later scholars have called syphilis and
typhus; the mysterious disease called “English sweats” appeared at that time as
well, and Europeans also became conscious of a great variety of “fevers.” Syphilis
and typhus both had considerable effects on the society of early modern Europe,
and syphilis especially stimulated interesting medical and social responses in
the sixteenth and seventeenth centuries. But the “newness” of each of these dis-
eases remains in doubt, and hence their relationship—so attractive at first glance
because of coincident chronology—to the great age of exploration also may not
be a simple one.

Syphilis apparently first appeared in Italy in the middle 1490s, in the
wake of warfare; contemporary accounts associated it with the invasion of Italy
by the armies of Charles VIII of France in 1494–95. Armies of that era were
almost ideal disseminators of disease: dirty, ill-disciplined, drawn from the far
corners of the Continent, disbanded at the end of each campaign to scatter back
into the far corners. After its first appearance in 1494–95 syphilis spread swiftly,
to be reported all over Europe by 1499. By that date it had also reached the
Middle East and North Africa; China experienced it within the next decade.
Where had it originated? A few years later—and just when is open to different
interpretations—it came to be believed that Columbus’ men had brought it back
from America, and this “Columbian” theory of syphilis commanded scholarly
support for a very long time. Some contemporary Europeans, convinced of its
64 The Burdens of Disease

novelty, blamed it on someone else: “Naples disease,” “French pox,” “German

pox,” “Polish pox,” for instance. But clinical descriptions of disease from before
the 1490s, in either Europe or Asia, remain subjects of scholarly controversy. Nor
is there consensus about the evidence of syphilitic bone damage (or lack of it) in
Old World skeletal remains.
But not all observers of the early sixteenth century were convinced either that
the disease was American, or that it was new. There were, to be sure, some
contemporaries of Columbus, themselves witnesses—Oviedo, Diaz de Islas, Las
Casas—who later said that they associated the disease with people returning
from America in the 1490s, but their writings were retrospective, with Oviedo
apparently the earliest in 1526. Other contemporaries, however, spoke more gen-
erally (and traditionally) about the causes of the disease as the wrath of God
and/or unfortunate conjunctions of the heavenly bodies. The common sixteenth-
century terms for the disease—Naples disease, French pox—reflect a view that
the horror came from sinful neighbors, not necessarily American Indians.
Finally, early in the sixteenth century some scholars found biblical or classical
texts that seemed to describe some similar ailment; certainly Europeans (and
Muslims as well) had long been bedeviled by diseases that caused appalling skin
lesions, with leprosy only the most famous.
Was this disease simply some new (or perhaps old) variant on such familiar
visitations? That old question, debated over the centuries first by reference to the
medical texts of antiquity and then (since the nineteenth century) by paleo-
pathology, has gained new complications from modern bacteriology and molecular
biology. Venereal syphilis results from an invasion of the body by a bacterium of
the genus Treponema; this genus is part of a group of bacteria called, from their
shape, spirochetes. Several species of Treponema exist, whose genetic relation-
ships (according to recent molecular analysis) form a “tangled skein.”1 They are
responsible for several distinct diseases (distinct in the sense of clearly different
symptoms), including, in addition to venereal syphilis, yaws and pinta (tropical
diseases most common in, respectively, Africa and Central America), and “endemic”
syphilis (called bejel in the Middle East), a relatively benign complaint.
This complex bacteriology has provided fodder for considerable historical
speculation. Some have maintained an extreme “unitary” position, arguing that
only one treponematosis exists, that it has existed in the human population as a
whole for millennia, and that it has taken different forms depending in part
on its transmission route into the body.2 Yaws and bejel flourished as endemic
childhood diseases in hot climates, among communities of little clothing and (in
E. H. Hudson’s words) “low levels of personal and community hygiene”; when
the organism reached urban populations in temperate climates it found its person-
to-person routes (skin contacts) broken by clothing and more regular bathing
habits, and so it gradually evolved as an adult infection transmitted venereally.
New Diseases and Transatlantic Exchanges 65

In this view Columbus (and the American Indians) had nothing to do with its
sudden appearance in Europe, which was not so much sudden as a suddenly
noticed phenomenon that had been slowly evolving. Some modifications of this
basic “unitary” position maintain that different treponematoses are responsible
for different diseases, and that they may have evolved differently among differ-
ent, and geographically isolated, human populations.3
Was venereal syphilis new to Europe in the late fifteenth century, and did it
reach Europe from the Americas? Paleopathological conclusions are ambiguous,
although treponematoses were both “present and variable” in America before
European and African contacts,4 and more American skeletons have treponemal
bone lesions than are found in those of the Old World. At least some contempo-
rary Europeans were convinced that they confronted a new disease (wherever it
originated), and their writings provide some clinical evidence for that belief.5
The virulence of the disease in the early sixteenth-century European population
was characteristic of an epidemic striking new ground. Strengthening the “new
disease” case is a weakness in one of the countering possibilities: for medieval
leprosy seems to have been just that, not syphilis. But it is also very likely that
some form of treponemal disease existed in Europe centuries before Columbus’s
voyages. Perhaps bejel had made its way to Europe from the Near East; perhaps
yaws had migrated from Africa. Certainly both were long established on the
Eurasian/African landmass, so the possibility remains that the apparent
Columbian explosion of a new disease really started within Europe itself as a
mutation of one of those other treponematoses.
Wherever it came from, the disease made a great impression on European
observers in the early sixteenth century. Its dramatic symptoms gave rise to
expressions of horror, as writers described the initial genital chancres and then
the succeeding skin lesions and skeletal aches that accompanied the several
years of the disease’s secondary phase. No estimates have been made of its mor-
tality or morbidity in the early decades of the sixteenth century, but contempo-
raries leave little doubt of its wide extent. The symptoms, especially the initial
genital sores, led most (though not all) to associate the disease with sex. Fear of
such a contagion fed already-existing suspicion of indigent transients; in
sixteenth-century France statutory attempts were made to isolate such danger-
ous characters, or to lock them up. “Pox” victims were an especially obvious and
inviting target for such regulation, although its implementation remained inef-
fective. Syphilis and its association with sex conferred on prostitutes a particular
air of danger, and demands grew that they be regulated, confined, or outlawed.
Sixteenth-century attempts to do so did not work, but in subsequent centuries—
especially the nineteenth and twentieth, when the regulatory efficiency of the
state vastly strengthened—prostitution and syphilis assumed the central roles in
important social morality plays, the subjects of further discussion in Chapters
66 The Burdens of Disease

Eleven and Twelve. And certainly the sixteenth century conviction of the conta-
giousness of the “Great Pox,” as it was known, also strengthened a growing gen-
eral predisposition to see diseases in a contagious light.
This terrible “pox” showed some signs of abating (in both incidence and viru-
lence) as the sixteenth century advanced. Perhaps more people now survived its
earlier stages, so that tertiary stages could become clearer. Descriptions of it
came to focus on the persistent lesions and frightening disfigurements that
marked its later stages, and writers paid more attention to the symptoms of those
who had clearly had the disease for a long time, rather than noticing a continuing
increase in new cases. (The different stages of syphilis, interrupted by periods of
latency, undoubtedly complicated and confused descriptions and diagnoses;
“pox” remained a broad brush for what may have been a variety of diseases.) If
contemporaries were right, and the disease receded from its savage first attacks,
such a recession would be consistent with a “Columbian,” or at least a “new,”
view of the disease, as after several generations people and microorganisms may
have been reaching a balanced relationship.
Galenic theory generally held that the pox was a disorder related to humoral
imbalances, and that theory underlay most sixteenth-century therapy. While differ-
ent authorities cited different humors as the offenders, phlegm emerged as the
favorite. So while bleeding was sometimes urged, the usual treatment involved the
expulsion of phlegm by the promotion of spitting and sweating. Two substances in
particular came to be employed for that purpose: guaiacum and mercury.
Guaiacum, one of the hardest woods known, is found in the West Indies and
Central and South America. Its European use as a cure for syphilis began some-
time after 1510 under unclear circumstances; its popularity owed much to an
influential book by the German humanist Ulrich von Hutten (1488–1523), De
guaiaci medicina et morbo gallico, published in 1519.6 Von Hutten’s tract carried
the authenticity of a sufferer from syphilis as well as the vigor of a controversial-
ist active in the defense of Martin Luther. The Augsburg banking and merchant
house of the Fugger established control of the marketing of guaiacum and heav-
ily promoted its sale, an example of the antiquity of enthusiastic peddling of
remedies. Its virtues were hailed, its prices soared, and pieces of the wood were
hung in churches as objects of veneration. It received names consistent with
such faith: lignum vitae, or even lignum sanctum. Some of the belief in its effi-
cacy arose from its American origin. If the disease was American, the widely
accepted “doctrine of specifics” argued that since God always paired diseases and
remedies, an American disease must have an American remedy. (Later opponents
of the Columbian theory wondered whether the argument did not run the other
way: since this American wood was a cure, the disease must be American. A pre-
cise dating of the first use of guaiacum, and of the first belief in the Columbian
theory, would be revealing.)
New Diseases and Transatlantic Exchanges 67

According to von Hutten, the guaiac medicine was prepared by grinding the
wood to a powder and then boiling the powder in water for a specified time. The
resulting liquid was the medicine, drunk as a potion. While he administered this
medicine, the physician confined the patient to a heated, sealed room, wherein—
drinking much liquid potion—the patient perspired profusely, thus expelling the
offending phlegm. Different sixteenth-century authorities prescribed variations
on this therapy, but they generally agreed on conditions that promoted sweating.
Not all physicians concurred with the guaiac treatment. Many combined it
with mercuric compounds, or used those compounds exclusively. Mercuric ores,
and substances prepared from them, had long been favored (especially by Arab
physicians) in the treatment of skin disorders and sores. “Arabic ointment,” most
often ore cinnabar (mercuric sulfide), was rubbed on the lesions. This treatment
was applied to the earliest “new” cases of the disease in the 1490s, only to be
overshadowed for a few decades by the rage for guaiacum.
One of the most influential authorities on syphilis, Girolamo Fracastoro
(1483–1553), took a cautious position that advocated both remedies. In 1530
Fracastoro wrote a long poem about the disease, Syphilis sive morbus gallicus,
notable as the origin of the modern word for the ailment; “Syphilis” was a shep-
herd who brought the pox on himself by his acts of blasphemy, illustrating
that the connection of the pox with sex was still not universally accepted. (The
word “syphilis” did not, however, begin to supplant “pox” until the eighteenth
If Fracastoro illustrated ambivalence about the use of guaiacum and mercury,
his contemporary Paracelsus had no doubts, and his arguments helped mercuric
compounds regain their primacy. Paracelsus stands as one of the major figures
in the history of science, medicine, and disease; his philosophy and its implica-
tions will be discussed in Chapter Five. For the moment it is sufficient to notice
that Paracelsus’ general objections to the ideas of Aristotle and Galen led him to
oppose many of the plant and herbal remedies associated with the Galenic and
Hippocratic traditions, and to urge instead the use of metallic or inorganic chem-
ically prepared substances. For him mercury was a particularly sovereign sub-
stance, for he (following some Arab traditions) believed that mercury was one of
the fundamental “principles” of nature. By the mid-1500s mercury compounds
had resumed their place as the favored treatment for syphilis, a position that they
held into the nineteenth century. Their effects pleased not only Paracelsus but
the Galenists whom he opposed. Their use produced immense quantities of
saliva (the offending phlegm being expelled), which was in fact a classic symp-
tom of mercury poisoning. And while mercury compounds became the favored
treatment, guaiacum remained as an alternate (it was, for example, listed in the
British Pharmacopeia until 1932), although its only possible curative effects were
68 The Burdens of Disease

The history of syphilis in the sixteenth and later centuries has attracted some
historians of medicine in part because of its associations with the ailments of notable
persons. Thus the policies, personalities, and careers of such rulers as Francis I of
France (1515–1547), Henry VIII of England (1509–1547), and Ivan IV of Russia
(1533–1584) have sometimes been interpreted as influenced by their supposed
syphilitic afflictions. It is an exciting prospect to explain by a clear simple cause—a
disease— Henry’s apparent infertility, his increasing ill temper, and, indirecdy his
break with the Roman Church, or Ivan’s paranoid cruelty that had such a crucial
effect on later Russian history. Such arguments make disease (as it has affected
individuals in this case) an important causal agent in human history as a whole.
Two substantial difficulties with such easy answers should be remembered,
however. First, precise physical diagnoses of individuals, when undertaken
across the centuries, are very chancy. Henry VIII may serve as an example of the
pitfalls. That monarch threw his life, and nearly his entire kingdom, into a tur-
moil in his search for an heir who would secure his shaky dynasty. He had at
least four children (by four different women) who survived infancy, but none of
them had children in turn. Did their failure to conceive stem from an inherited
syphilitic infection? Add to that circumstance Henry’s headaches and sore
throats, ulcerated legs, and changes in his character as he aged, and a case might
be made for Henry as a syphilitic.7
But close students of Henry VIII, including his modern biographers, have
convincingly argued against the diagnosis of syphilis. They have suggested
depression (perhaps brought on by his worries about the legitimacy of his first
marriage) and the serious effects of the ulcerated legs that developed as he aged.
Milo Keynes, in a recent medical analysis of the case, cites the absence of the
telltale rash of the “Great Pox” in Henry, as well as the king’s continuing mental
acuity. And—most convincing—no evidence exists that Henry was ever treated
for syphilis, although he lived in a time when the disease attracted great atten-
tion and when cures for it were widely prescribed. Francis I of France was treated
for syphilis. If Henry had syphilis, why didn’t his doctors treat it?8
There exists a second, substantial objection to the use of royal illness to
explain decisive points in history. Simply put, historians are—and should be—
suspicious of any simple, unicausal explanation of complex historical phenom-
ena. That the fall of the Napoleonic Empire can be attributed to the great man’s
ulcers, or to his stomach cancer, is a laughable oversimplification. This is not to
deny that individuals and their actions have an important and often crucial role
in the pattern of historical change. But a very risky trail leads from want of a nail
to the fall of a kingdom. Sensitive and careful studies of the relations of an indi-
vidual’s health and his public policies do exist—for example, Roger Williams’s
The Mortal Napoleon III—but they require thorough biographical and historical
understanding of contexts more than a diagnosis that provides a magic key.9
New Diseases and Transatlantic Exchanges 69

English Sweats
Syphilis appeared in Europe simultaneously with two other noteworthy
diseases, a fact that has encouraged speculation about the widening of world dis-
ease pools. Both these “new” diseases, like syphilis, were first associated with
warfare and the movement of troops; they were typhus and the ailment that came
to be known as “English sweats.” In the former case the military association was
probably a sound one, but in the latter it was likely coincidental. The English
sweating sickness first appeared in that country in 1485, which later gave rise to
the theory that mercenary troops involved in the Wars of the Roses (specifically
the invasion of England by Henry Tudor) carried the disease. The sweats reap-
peared in England four other times—in 1508, 1517, 1528, and 1551—on each
occasion remaining in that country only; they made one appearance elsewhere
in Europe, in 1529–1530. Contemporary descriptions carefully differentiated this
disease from plague, typhus, and malaria; they further noticed that young upper-
class males were particularly susceptible to it.
The English sweating sickness made a dramatic impression in part because
of the prominence of its victims and in part because of its sudden and lethal char-
acter. Accounts from 1517 speak of its victims perishing very quickly: “Some
within two houres, some merry at dinner and dedde at supper.”10 But its demo-
graphic impact was relatively slight, and it did not establish itself. After 1551 it
vanished. John Wylie and Leslie Collier, careful students of the English sweats,
have concluded that an arbovirus originating in northern and eastern Europe
caused these epidemics. Such arboviruses may be enzootic among small mam-
mals (such as mice) and carried to people by insects. A new virus strain, Wylie
and Collier theorize, invaded England and attacked those people in the society
who might most frequently encounter insects (active young males) and those
who might have constituted an immunologically virgin population, especially
young adults.11 The attack on young adults may also have characterized
sixteenth-century syphilis in Europe, and such a pattern might explain the
violence of the early epidemics of English sweats. The latter’s disappearance
from the scene after 1551 may have been the product of changing small-mammal
populations and their immunities, or some other interference with the complex
virus-reservoir-vector-human route.

The English sweats remain a subject of historical conjecture, if only
because their disappearance makes certain diagnosis impossible. The third
“new” disease in Europe in the age of Columbus, typhus, rapidly established
itself as a major problem and remained so for centuries. Typhus first claimed
attention as a new disease in 1489–90 in the course of military operations in
Spain, where the Moors resisted the attempts of the Spanish Christian kingdoms
70 The Burdens of Disease

to conquer Granada. The victims of the new disease suffered an acute fever, fol-
lowed by a rash, headaches, delirium, and general debility, followed in turn by
an alarming proportion of deaths; not perhaps as high as that inflicted by plague,
but serious enough, especially among the armies where the disease seemed
most at home. Contemporaries believed that typhus came either from corpses or
from soldiers who had been in the East, perhaps Cyprus where the Venetians
employed an army against the Turks. As with syphilis and plague, conviction
that typhus was contagious dominated sixteenth-century etiological thinking.
In fact these contagion notions, and their associations with armies, were fairly
accurate, although the “newness” of typhus in the late fifteenth century remains in
question. A very small organism, of the family called Rickettsia, causes typhus.12
Such organisms are smaller than bacteria (though larger than viruses); they are
responsible for a number of diseases, including Rocky Mountain spotted fever and
Tsutsugamushi fever as well as typhus. Different Rickettsia species are at home in
populations of small mammals and insects: fleas in the case of typhus, ticks in the
cases of Rocky Mountain spotted fever. Ordinarily the organisms infect only their
rodent and insect hosts, and humans enter the picture accidentally when they inter-
rupt the path of a flea or tick that customarily prefers another host. The Rickettsia
diseases therefore share something of plague’s epidemiological pattern.
But also like plague, typhus can become epidemic in human populations and
be passed from one human to another. Typhus in its murine form, passed from
rodent to rodent by fleas, probably originated in Asia and most likely reached
Europe long before 1489, infecting the occasional European who got in the way.
Only in 1489 did it reach a serious epidemic stage, when it began to be transmit-
ted directly from one person to another by lice. Human lice (both “body” lice and
“head” lice) make their homes on humans and their clothing, unlike fleas, which
hop on and off. Lice therefore have much more dangerous potential as carriers
of Rickettsia organisms. In 1489 an epidemic most likely began when a critical
mass of humans—some infected—gathered, and within that mass a person-to-
person transmission of typhus began via lice.
For that purpose the armies of late medieval and early modern Europe
afforded nearly ideal conditions: they contained large masses of unwashed and
ill-nourished people living an undisciplined life in which they foraged over the
countryside and lived in close proximity to others. And not only did armies prop-
agate typhus; warfare disrupted whatever public health measures might be
attempted. From the standpoint of health, the European armies of the sixteenth
and seventeenth centuries often combined the worst features of their predecessors
and successors: shakily controlled by still-impoverished governments that some-
times could not afford to pay them, yet equipped with the fearsome firepower of
cannons and musketry, the early modern mercenary army was a particular threat
to whomever got in its way, whether friend or foe. Not only did it practice direct
New Diseases and Transatlantic Exchanges 71

violence, whether under discipline, or told to forage plunder for itself, or given
the freedom of a captured city; it remained basically unwashed, itinerant, and
promiscuous, a powerful agent for the diffusion of disease. And its enhanced
destructive powers made it all the more likely that its incursions could com-
pletely break down the fabric of a community it attacked, including whatever
provisions for health and sanitation existed.
So while the contagious character of typhus was appreciated early (although
the role of the louse—and of course that of Rickettsia—was only understood in
the twentieth century), early modern states had trouble controlling its spread.
They erected barriers to the spread of contagion, as we have seen in the previ-
ous chapter. But it is hard to imagine the thousands of members of an armed
rabble stopping at a border to show their health passes; and states never consid-
ered disbanding their armies in the name of public health.
Once typhus epidemics established themselves in the wake of armies, they
both played a major role in the military campaigns per se and eventually (per-
haps by the 1560s) built up a pool of infected Europeans that sustained typhus
epidemics in Europe continuously from that date until World War I. In that long
period typhus hounded every European war and persisted in every poor, over-
crowded, unwashed population. Only a few examples are necessary here to make
the point.13 In the prolonged struggles between Hapsburg Spain and Valois
France in the sixteenth century, typhus sometimes played a decisive role, as for
example in 1528 when it broke up and scattered a French army besieging Naples.
Spanish primacy in Italy was thus strengthened, which in turn affected the
Hapsburg-Spanish position in Reformation Germany. Hans Zinsser, the author
of a classic study of the history of typhus, calls the Thirty Years’ War (1618–1648)
“the most gigantic natural experiment in epidemiology to which mankind has
ever been subjected”; certainly no collection of military campaigns in Western
history presents such a grim picture of invading disease accompanied by pillage
and rapine.14 By the eighteenth century some governments placed their
armies under more reliable control (which included more reliable pay), so that
their menace to health may have declined. But terrible examples persisted:
Napoleon’s failed Russian campaign of 1812, for the disasters of which winter
weather is often blamed, suffered massively from diseases of which typhus was
the most notable. Any student of the military history of sixteenth-, seventeenth-,
and eighteenth-century Europe must take the ravages of typhus into account.
Yet appalling as some of those numbers may be (17,000 Christian soldiers dead
of typhus in Granada in 1489, against 3,000 killed by the Muslims), the losses to
new diseases in early modern Europe are dwarfed by the contemporary experi-
ences of the Americas. For the natives of America, encounter with European dis-
eases proved disastrous, and their experiences form an important part of the
story of the West’s disease relations with the rest of the world.
72 The Burdens of Disease

New Diseases in America

The European expeditions across the Atlantic begun by Christopher
Columbus in 1492 led to the conquest of a sizable proportion of the Americas
within a century and precipitated the greatest demographic disaster in history.
Although scholarly debate persists about the numbers, the population of the
Americas in 1500 may have been between fifty and one hundred million. By the
middle of the seventeenth century that number had almost certainly fallen below
ten million, and perhaps below five million.
This horrific depopulation had numerous (and interrelated) causes, among
which disease may take pride of place. Much attention has been focused on the
sudden appearance of new epidemic diseases in the American population, and
those terrible episodes undoubtedly played an important role both socially and
demographically.15 But some of the demographic collapse of the Americas may
be explained by less dramatic workings of disease, in which illness worked con-
jointly with the drastic social effects of an alien conquest.
In the centuries before Columbus American populations had undergone some
fluctuations, and some evidence suggests that about 1500 those populations may
have reached a high point, near (or at) the upper limit that the existing agricul-
tural technology could support. America’s demographic condition in 1500, there-
fore, may have paralleled that of Europe two hundred years earlier, at the time
when an overpopulated continent suffered famines in the decades that preceded
the plague epidemic of 1347–1350. The capacity for food production in the
Americas may have already been stretched thin before the Europeans arrived.
Massive human sacrifices, it has been suggested, may have been “an uncon-
scious mechanism for the control of population expansion.”16 In addition the pop-
ulation density in some parts of America—notably the Valley of Mexico and the
altiplano of Peru—had become very high. The cities of Cuzco and Tenochtitlan
may have been among the largest urban concentrations on earth.
The density of the American populations of Mexico and Peru remains a con-
troversial point, however. If Bernard Ortiz de Montellano is correct, neither high
population density nor inadequate nutrition characterized pre-Columbian
Mexico.17 The vulnerability of its population to epidemics therefore may not have
paralleled that of Europe in 1347. But social and biological factors certainly did
add to the vulnerability of Americans. Although many Americans fled in response
to the new epidemics, at least some may have valued ties to kin and to tribe and
so dispersed only reluctantly. Without clear theories of contagion, Americans
may have regarded disease fatalistically and hence passively. But it is also true
that many inter-American trade routes existed (including some by sea) that could
contribute to the diffusion of epidemics, as could of course flight.
More important was the biological problem. Beyond doubt, the American
population had been biologically isolated from the Old World for many centuries.
New Diseases and Transatlantic Exchanges 73

That isolation meant epidemiological vulnerability, although disagreement per-

sists about its nature. The causative organisms of some diseases—notably
smallpox but also measles, typhus, and plague—were evidently all new to the
Americans; when these maladies traveled with Europeans to the Americas they
fell on what is sometimes called “virgin soil.” Subsequent documented experi-
ence with virgin soil epidemics has illustrated the savage character of such out-
breaks, which for some reason strike the young adult population with particular
severity.18 That may have occurred in sixteenth-century America, although we
have no age-specific statistics of mortality. Certainly the Americans had inher-
ited no immunities to the diseases suddenly loose among them. But were the
Americans also genetically predisposed to higher mortalities from diseases such
as smallpox? That possibility remains in question. In either case—whether they
simply lacked antibodies, or because their genetic makeup led to higher mortal-
ity from some diseases—the first American generations to meet the microorgan-
isms suffered very high mortality. Subsequent generations perhaps fared better,
either because the survivors acquired antibodies or because natural selection
eliminated those with genetic susceptibility to high mortality, or both.
Smallpox was probably the first of the epidemics, and it caused perhaps the
greatest single ravages. By 1519 the Caribbean islands of Hispaniola and Puerto
Rico had been devastated by smallpox, and in that year the disease moved to
Mexico. Its role in the astonishing conquest of the Aztec Empire by Cortez (and
his Amerindian allies) was considerable.19 By 1524 smallpox had spread through
the American mainland from Mexico south to the populous Peruvian civilization
of the Inca, so that by the time of Pizarro’s arrival in 1532 Peru had already been
crippled by disease, which the Inca regarded as a terrible omen. Measles arrived
in the Caribbean in 1529 and reached Mexico two years later; typhus, perhaps
accompanied by influenza, spread from Mexico to Peru between 1545 and 1547.
Another outbreak of some form of influenza was at large in the 1550s. Smallpox
reached Brazil in 1562, originally from Portugal, but by the seventeenth century
Brazilian smallpox epidemics were being fueled by the slave trade from West
Africa. The 1570s and 1580s were particularly catastrophic decades for the
Americans, as typhus and influenza assailed Mexico in the middle 1570s, small-
pox and measles fell on the Venezuelan coast, and smallpox worked its way north
from Peru through New Granada (Colombia). This repeated epidemic pressure
meant a continuing drop in populations. The pre-1492 population of the Americas
may never be known, but it is likely that by the seventeenth century the popula-
tion had fallen by about 90 percent from its 1500 level.20
The sheer number of different diseases, all new, differentiated the sixteenth-
century American experience from the fourteenth-century European one.
In Europe plague alone was not responsible for the death tolls of the 1340s and
later, but it was not simultaneously accompanied by other great new killers.
74 The Burdens of Disease

The Americans suffered a succession of different “plagues,” in the manner of the

ancient Egyptians at the hands of Jehovah, over a prolonged yet overlapping
period. Diseases spread, or became more severe, in the wake of one another.
Smallpox, measles, typhus, and plague were of course great killers, even of non-
virgin populations. And surviving one epidemic might leave an individual help-
less to face the next. Influenzas that might simply weaken had lethal results too,
for they left the system feebly unable to resist other “opportunistic” infections
such as pneumonia, or they weakened the people who provided care for infants.
The highest death rates in the Americas in the sixteenth century were consis-
tently recorded in the tropical, coastal, and island territories, perhaps because
the new diseases there fell on populations already weakened by malaria and
other insect-borne fevers.
The new diseases in America also interacted with a social and economic situa-
tion that had been radically changed by the abrupt European conquest. Violence
had been inflicted on the population, especially on the males; some demographic
data suggest that in sixteenth-century Spanish America females came to out-
number males significantly, as the latter fell victim to both violence and brutally
hard work. The imposition of plantation agriculture on parts of the New World
resulted in monoculture, poor diets, and situations in which livestock took over
the best arable land and left the natives cultivating soils of marginal productivity.
Cultural imperialism also took unexpected tolls on the diet of Americans; well-
meaning Christian missionaries insisted that the natives be clothed, arranged for
the plantation of cotton to provide cloth, and so removed arable land from food
The combination of inexplicable diseases, alien conquest, and brutal
rearrangement of social and economic systems contributed to widespread loss
of will, which in turn affected demography. Ill parents may simply have given up
hope and thus doomed their young children, perhaps through inadequate food,
nursing, and shelter from the elements, perhaps—more drastically—through
infanticide and suicide. But were native Americans simply helpless? Or did they
in fact demonstrate powers of resistance or cultural adaptation? Did they retain
some independent agency in their lives?
Unanswered questions about the epidemiology of the terrible sixteenth-
century diseases remain, and to consider some of them an introduction to small-
pox will help, although the disease receives a more thorough discussion in
Chapter Six. Smallpox is the product of infection by a virus, or rather one of a
closely related group of viruses. Little doubt exists about its antiquity, and clear
descriptions show that it was established in medieval Europe and the Middle
East. Smallpox is an acute infection, exposure to which confers a high degree of
immunity from further attacks. It passes directly from person to person, usually
by way of the respiratory system; only actively sick people can transmit it.
New Diseases and Transatlantic Exchanges 75

It meets, therefore, many of the requirements of a classic “childhood” infection,

since it persists in previously unexposed populations that (especially if it has
been long established in a population) it finds in the young.
Moving such an infection across the Atlantic in the early sixteenth century
must have involved a certain measure of chance, for the voyage was generally
longer than a month, the average length of an active smallpox infection. Unless
the passage were unusually fast, more than one previously unexposed person
would have to be on board for the disease to be sustained across the Atlantic and
thus passed to the Americans. The death of a victim would of course cut short
the period of possible infection and thus make transoceanic transmission more
But deaths of Europeans from smallpox may, in the sixteenth century, have
been relatively unusual, so that smallpox’s chances of crossing the ocean were
thus marginally improved. According to the recent arguments of Ann Carmichael
and Arthur Silverstein, smallpox had been a relatively mild childhood disease in
Europe for some centuries, down into the sixteenth.21 Medieval commentators,
both Muslim and Christian, regarded smallpox as a benign and perhaps even
necessary part of the maturation process. If that was so, smallpox’s transmission
across the Atlantic may be more easily understood, but another epidemiological
problem then arises.
The benignity or malignancy of smallpox may be accounted for by the fact
that the viruses are part of a genus whose members are in many ways indistin-
guishable, but whose effects are drastically different. Variola major may kill 25
or 30 percent of its victims; Variola minor, 1 percent or less. What happened
between Europe and America? Carmichael and Silverstein suggest three possi-
bilities. Perhaps, while most smallpox cases in Europe had been mild (probably
Variola minor), there had occurred occasional virulent Variola major outbreaks
in later medieval Europe, and (by terrible chance) one of those was transmitted
across the Atlantic to the American population. Alternatively, common Variola
minor made its way across the ocean, and in America underwent a mutation to
Variola major. As a third possibility, the American population carried genetic
weaknesses that made it susceptible to high mortality from the benign smallpox
known to Europeans. In any case, by the end of the century (or by the beginning
of the seventeenth) smallpox became a serious disease to Europeans as well,
although when its more lethal form spread in the Old World much of the popula-
tion already enjoyed some immunity from the centuries of experience with the
less virulent version.
Did the Europeans, especially the Spanish, deliberately foster disease among
the Americans? Did they practice bacteriological warfare and thus achieve a
desired genocide? First, we should remember that the great depopulation of the
Americas, especially in those zones conquered by the Spanish (the Caribbean,
76 The Burdens of Disease

Mesoamerica, and the Andean regions), occurred by the end of the sixteenth
century. In that period simple contact with the Europeans often brought disas-
ter, and in some cases diseases actually ran ahead of the physical arrival of the
Europeans themselves, as was true in Peru preceding Pizarro’s conquest. The
Spanish did not need to deliberately spread disease, but in any case they lacked
both a motive to do so and a clearly understood means. Europeans had no pre-
cise notion of the causes of smallpox, typhus, and plague. Although by the six-
teenth century doctrines of contagion were commonly held, any attempt to create
biological weapons out of human bodies or their clothing would have been
extremely awkward.22 In addition, the Spaniards founded colonies whose eco-
nomic bases were plantation agriculture and mining, both of which led to the
enslavement of large populations of workers. The Spaniards’ interests surely lay
in keeping the work force alive, not in the deliberate massacre of it.
This does not deny an abundance of malice in the European conquerors of
America, for they clearly stand responsible for deliberate horrors aplenty. Some
of those horrors grew out of the attempts of Europeans to exploit the labor of the
Americans, especially in the Spanish colonies. The interests of the later English
settlement differed somewhat; at least in some areas the English, settling the
land and replicating European society, wished to evict the natives, not put them
to work. So the English settlers might have had an interest in disposing of the
Americans. But by the seventeenth century, when the English arrived, smallpox
had become a lethal disease to Europeans too. Even had they known more of its
epidemiology than they did, the English may have been leery of using such an
obviously two-edged sword, which might spread from the Americans back to the
settler population. But it is also true that by the eighteenth century much clearer
notions of smallpox’s contagious character had become generally known, for
inoculation (see Chapter Six) came to be practiced under a variety of circum-
stances in many parts of the Western world, some of them on the “frontiers” of
America. Malicious English settlers (or their United States successors) who
wished to clear the natives away may well have hurled blankets soaked in the
“matter” of smallpox, and thus sowed a bitter legacy. But the great damage had
been done unconsciously and earlier.

Continuity and Change

Magic, Religion, Medicine, and Science,

A s we have seen, the Western world experienced new diseases in the

late medieval and early modern ages. Although in some respects those periods
of Western history present remarkable continuities in human responses to dis-
ease, some important new thinking about nature and disease also developed.
This chapter will first discuss widely shared social and individual responses, and
then consider new ideas that undermined many of the premises on which those
responses were based
Between the fifth and the eighteenth centuries the people of the West lived pre-
dominantly, or even overwhelmingly, in rural surroundings. Human and animal
muscle performed most work. Beliefs in supernatural powers explained the work-
ings of the universe, whether those beliefs were simply grounded in traditional
folk culture or highly elaborated in Thomistic Aristotelianism. Life expectancy
remained low and disease most often inspired fatalism, however much beliefs
about diseases and their causes may have changed. To such a sweeping set of
generalizations must be added many qualifying caveats. In some areas—northern
Italy and the Netherlands, for example—urban life early assumed considerable
importance and fundamentally changed economies and societies. The “simple
machines” of the science of mechanics, such as wedges and levers, magnified
muscle power, while wind and water alike were harnessed in a variety of ways.
By the eighteenth century the supernatural powers of the universe retreated
(at least for some thinkers) into the distant recesses of a mechanical deity muscle-
bound by the laws of human reason.
But the ailments of Western people, and the responses to them, remained on
the whole remarkably constant. Those responses included the employment of a
few pain-dulling narcotics and appeals to religion, to “magic,” to the services of a

78 The Burdens of Disease

wide range of empirics, and to the official mercies of professional medicine.

Sometimes those responses overlapped; indistinct boundaries divided science,
religion, magic, empirical healing, and folk custom. And to some undoubtedly
considerable extent, people also responded to their ills by doing nothing, some-
times with iron stoicism, sometimes with vocal complaints of a kind as familiar to
the twelfth century as to the twenty-first.
Much of this book concerns the effects of, and response to, more or less vio-
lent epidemic visitations: plague, leprosy, smallpox, tuberculosis. But all through
the medieval and early modern periods everyday ailments affected the people of
the West as well. Many of those troubles stemmed from nutritional deficiencies.
Others were not so much chronic as occasional, especially the wide range of gas-
trointestinal disorders and the even wider variety of viral ailments and “colds.”
Some natural immunity to those complaints might develop, but the causative
viruses themselves underwent frequent variation. A population that worked with
the strength of its muscles and the leverage of its bones fell victim to osteoarthri-
tis, bursitis, rheumatism, and other sorts of aches and pains. Diseases of physical
degeneracy and aging awaited those who survived epidemic infections; cancerous
tumors were well known; and psychiatric illness, called by a wide range of names
and treated in an equally wide range of ways over these centuries, added to popu-
lar burdens. And of course difficult physical work often meant high rates of acci-
dental injury; the maimed were a common sight in the medieval and early modern
centuries, the products of accident, violence, birth defect, or progressive disease.

Modes of Healing
For centuries people of Western civilization found in alcohol (some-
times in combination with opium or mandrake) their first defense against pain,
and some evidence suggests that alcoholic drinks became more important and
pervasive in the later Middle Ages, perhaps as a consequence of the greater dis-
posable income available in the labor-scarce, land-cheap economy of the years
after the onset of plague.1 But when the consolations of alcohol failed to relieve
pain or banish care about illness, sufferers called for the aid of others. Those oth-
ers might employ religion, magic, empirical remedies, and perhaps “medicine”;
and while those categories were partially congruent, a consideration of each of
them may clarify attitudes toward disease and practices of healing in the long
preindustrial, preurban age of Western history.

Christian religious practices played a major healing role. For a start,
God’s will loomed as a major—perhaps the major—etiological explanation of
disease, a notion that certainly antedated Christianity but that Christians
maintained. Particularly important in medieval Christianity were the cults of the
Continuity and Change 79

saints, for saints might intervene with God on behalf of a sinful (and ailing) sup-
pliant. Saints and their relics emerged as important healing aspects of Christianity
for a number of reasons. The competing deities of the old Roman Empire had
claimed some healing powers (as did, notably, Asclepios and his votaries), and
some of those pagan traditions merged into Christianity (see Chapter One).
Some early healing saints were certainly Christian versions of pagan gods. Early
Christian missionaries found the performance of miracles (such as healing) a
strong card to play when they confronted, and converted, the heathen Germans
and Slavs. Furthermore, the relics of the dead (such as bones) both shared a pow-
erful juju with other religious traditions and could be easily carried by itinerant
A large number of shrines associated with such holy relics grew up in the Middle
Ages. Some shrines became famous all over Western civilization, including those
of St. James of Compostela in Spain and St. Thomas à Becket in England. They
drew pilgrims from considerable distances, and might therefore be crowded with
those with the means to undertake lengthy and expensive journeys. A much
larger number of shrines enjoyed a strictly local celebrity. In some cases the
hierarchy of the Church recognized these places as associated with “official”
saints, but in many others the local population venerated semilegendary figures,
those who had not been canonized at all, and subjects of folk legend that perhaps
antedated Christianity.
The story of St. Guinefort, unraveled by Jean-Claude Schmitt, illustrates well
the tangled relationships of such shrines and popular faith in their healing pow-
ers.2 St. Guinefort was originally associated with Pavia, in Italy, where his relics
were venerated for their curative strength. His cult spread to regions of France,
and popular belief there conflated the saint and a legendary “Holy Greyhound,”
a loyal dog slain by its owner in the mistaken belief that the hound had killed
the master’s child. The master had returned home to discover a blood-spattered
dog and house, and had reached his awful conclusion. When the mistake was
discovered—the child safe, the blood that of a serpent killed by the dog defending
the infant—the repentant master buried the dog with great ceremony and the
grave became a site of healing rituals for sick children. In the thirteenth century
the Church’s Inquisition denounced this story (and its associated practices) as
superstition, but, as Schmitt has shown, some version of belief in the holy grey-
hound’s healing powers persisted until the early twentieth century.
The Church made many efforts, especially from the twelfth century on, to
bring such beliefs into conformity with orthodox theology. But as Ronald
Finucane notes, “public demand for relics was far stronger than public obedi-
ence to church regulations,” so attempts by the hierarchy to regulate the shrines
often had little effect.3 And in any case, even the most orthodox and approved
shrine might be the object of unorthodox beliefs and hopes. Why did a pilgrim
80 The Burdens of Disease

travel to a shrine? The answer might lie locked in his or her heart, or even
subconscious. R. A. Fletcher, speaking of St. James of Compostela’s shrine, puts
the matter clearly: “The solemn notes which have been sounded here—contrition,
amendment of life, deepening of Christian observance—may not have sounded
for him [the individual pilgrim] at all. Most pilgrims (we may suspect) were per-
fectly ordinary people with only the humdrum problems of daily life to contend
with; provided always that we bear in mind that that little word ‘only’ can mask
whole worlds of tempestuous and ghastly experience.”4 Fletcher’s study of visitors
to St. James’s shrine shows people fleeing from plague, barren couples hoping for
a child, paralytics and cancer victims seeking cures, and even those theoretically
on pilgrimage but in fact engaged in an armed expedition to loot the
Mediterranean basin.
Among those drawn to the shrines, regardless of the orthodoxy of the holy
places, were the sufferers. Perhaps the shrine’s reputation, either in a locality or
as specializing in particular ailments, attracted them. Perhaps they came only
after other recourses—alcohol, their local priest’s prayers, the medications of an
empiric—failed them. According to Finucane, who studied the records of English
shrines, the most common ailments for which relief was sought varied according
to social class.5 The lower orders, both men and women, brought their crippling
illnesses and blindness and troubles brought on by malnutrition, lives of toil, and
(in the case of women) complications of childbirth. Men from the upper class,
not surprisingly, brought their battlefield wounds. All the suppliants prayed at
the shrine, hoping to get as physically close to the relic as they could; they also
consumed waters associated with the shrine, if any such existed. Procedures
rooted in folk custom might help: for example, measuring the sufferer’s height
with a string and then using the string as the wick in a votive candle to be burnt
at the shrine. Pilgrims waited for some signal turn of events: a dream, or a dra-
matic moment of crisis in their pain. When they were convinced that a cure had
taken hold they departed, first making offerings of coins, candles, or objects
associated with their affliction such as crutches or slings.
The Church’s position on the validity of these curative shrines was very
ambiguous. Although the hierarchy inveighed against superstition and the
Church theoretically could not compel natural events, priests regularly blessed
everyday activities (such as the planting of crops) and extraordinary ones
(armies going into battle), and for many onlookers such blessings implied some
power over the course of nature. The sacraments, especially the holy water of
baptism and the elements of the Mass, possessed apparent magical powers. As a
number of authors have noticed, the popular belief in the powers of the elements
led to thefts of the bread and the wine, which led in turn to the Church’s attempts
to secure them in locked monstrances, which security (and display) simply con-
firmed popular belief in their magical powers.
Continuity and Change 81

In addition, in the early Middle Ages, if any knowledge of Greco-Roman med-

ical traditions and writings survived in the West, it could be found in monastic
communities, which meant that monks might offer some medical treatment as
well as spiritual help. To those drawn to them the distinctions may not have been
clear. As the Church’s priests acquired some of the learning of the cathedral
schools and universities (after the twelfth century) some of them inherited the
earlier position of the monk: the person in the village community who might
have some smattering of Galenic ideas as well as the power to perform the mira-
cle of the Mass.
The position of kings offered further examples of the Church’s ambiguity
about religion’s power over nature. Western kings increased their prestige and
gained respect by surrounding themselves with pomp and ceremony at their
coronations, and the Church cooperated in these rituals, consecrating kings with
holy oil. When (in the thirteenth century) the papacy contested the miraculous
powers of the French and English kings to cure scrofula, it was belatedly realiz-
ing that it had encouraged a view that religious ceremony meant control over
nature’s course. And in any case the Bible itself seemed to license the idea that
the God of the Israelites was a supreme magician, who could part the Red Sea
and bring the chariot of the sun to a halt when so requested by Joshua. When
Jesus was born magi visited him; when he grew to manhood he caused the lame
to walk and the dead to rise up.

All these factors, and their perception in the ordinary medieval mind,
lend support to Richard Kieckhefer’s argument that neat divisions of the realms
of religion and magic are likely to founder on the complexities of medieval and
early modern culture.6 Kieckhefer argues that medieval thinkers came to see dif-
ferent categories of magic: “natural” magic, which dealt with what all agreed were
the hidden, or occult, powers of nature; and “demonic” magic, a perversion of reli-
gion.7 And while before the twelfth century (according to Kieckhefer) Christian
thinkers saw all magic as “demonic,” in fact many classical, pagan, early Christian,
Norse, and Celtic beliefs eroded those Christian denunciations. After the twelfth
century, natural magic gained acceptance as a legitimate branch of inquiry.
Natural magic, which attempted to understand the hidden powers of nature,
was bolstered by philosophy as well as by religion. These relations were clearest
in the late Middle Ages and the period of the Renaissance, when neo-Platonic
doctrines gained wider currency among thinkers. Neo-Platonic beliefs insisted
on the complete interrelation and mutual responsiveness of the different phe-
nomena of the universe. Events in the “macrocosm”—the greater world of astro-
nomical phenomena—affected or even mirrored events in the “microcosm,”
the individual. Harmonies vibrated between the heavens and the individual,
82 The Burdens of Disease

or between large natural events and human physiological processes. To under-

stand man, the thinker must understand the macrocosm. “Understanding” might
entail more than a simple process of rational analysis; the thinker should become
attuned to the harmonies of the universe, should be sympathetic to microcosm
and macrocosm alike.
Studies of alchemy and astrology therefore loomed large in the neo-Platonic
understanding of nature. Astrology clearly rested on the belief that events in the
heavens influenced or mirrored the lives of individuals; alchemy pursued chemi-
cal changes that would lead to “purified” metals (ultimately gold) and elixirs
(which would confer health). Before purifying metals or elixirs, the alchemist
had first to purify himself. The distinctions that later thinkers, in the Cartesian
tradition, made between “matter” and “spirit” simply had no meaning to the neo-
Platonist. Renaissance neo-Platonism, or naturalism, filled the universe with life
and volition and so approached pantheism. It believed that powers were at large
in the universe, powers that might possess their own will to act, powers that the
knowing might harness, perhaps to effect a cure.
For many reasons, therefore, the beliefs both of devoutly Christian priests
and monks and of Renaissance court thinkers overlapped the practices of folk
empirics who, drawing on some arcane knowledge of nature, called down super-
natural powers to aid in their healing arts.

Empirical Healing
Folk medicine involved a varying mix of religion, magic, philosophy,
and tradition. Activities might include the bleeding and purging consistent with
Galenic theory, attention to diet, the herbal traditions of both the classical
authors (such as Dioscorides) and the trial-and-error empirics, the practices of
surgery and midwifery, careful attention to routine, the employment of what
Keith Thomas has called “technical aids,” arcane language, and religious formu-
las and incantations in which the routinely orthodox Christian prayer existed
along a continuum with appeals to the occult powers of nature or even to demons.
Scholars who have written about the healing activities of medieval and early mod-
ern Europe have found generalization difficult, for the local variations were
almost innumerable. Some common elements did exist, however.
Many healers employed some combination of herbal remedies, often together
with animal parts. Trial and error produced many of these medications, as it had
for centuries in different cultures. Perhaps some of the monks and priests who
found themselves in healing roles had some acquaintance with ancient Greek or
Roman authorities, but perhaps not. For many healers some element of magic
inhered in particular herbal remedies. The preparation and administration of
these materials might follow a definite routine, which might be designed to
ensure reliability or perhaps to avoid taboos which, if violated, would weaken
Continuity and Change 83

or destroy the healing power of the herb or indeed of the healer. “Technical aids”
might accompany the administration of the remedy: ducks’ bills placed in
patients’ mouths, dipping victims in flowing water, examining the belt of a preg-
nant woman.8 Because of their local character the symbolism of these acts was
often extremely obscure, although some—opening and closing doors and draw-
ers to assist women in labor—seem obvious.
Words often accompanied such actions: prayers, some of them (Hail Marys,
Paternosters) ordinary enough, some of them specific to a particular ailment
(“Jesus Christ for mercy’s sake/Take away this toothache”), and some of them
best described as gibberish, at least to the sufferer.9 Gestures might attend the
words; some curative power might reside in the healer’s touch. Some touching
powers were thought to be God-given, or the gift of inheritance. For obscure rea-
sons of mystical numerology, seventh sons were widely credited with a healing
touch, and seventh sons of seventh sons had extraordinary power. The consol-
ing or comforting touch of a healer might not need any magical explanation at
all, but such gestures of kindness surely, if insensibly, shaded into the efficacy of
supernatural power.
Notable here were the “strokers” of the sixteenth and seventeenth centuries,
whose claims in England and France ran the risk of poaching on royal healing
preserves. Where the rulers had asserted a specific healing power in their touch
(see Chapter Two), they might be jealous of infringements. Thus Jacques-
Philippe Boisgaudre, a reputed seventh son, found himself prosecuted in
England in 1632, and James Leverett was imprisoned and whipped in 1637, for
offering healing competition to Charles I. The most famous seventeenth-century
stroker, Valentine Greatrakes, attracted a large following in the 1660s, which
included such eminent men of science as Robert Boyle and John Flamsteed.
Greatrakes retired from the healing field rather than contest it with Charles II,
but although his contemporaries disagreed about whether his powers were
“natural” or “magical,” they united in respecting them.10
Materials had real importance as well. Symbolic considerations entered into
the selection of both medications and talismans.11 Yellow materials might be pre-
scribed for jaundice; amulets offered protection from illness, perhaps because
of their inherent virtue, perhaps (if they carried words or letters) because of the
talismanic power of the inscriptions.
Women carried on a considerable proportion of empirical practice,
especially— but not exclusively—that which applied to women’s health in gen-
eral and to births in particular. Some women could be found at all levels of
medieval and early modern healing, including physicians, although few of the
latter have been identified. Monica Green suggests that the position of women
healers evolved in a way that reflected the increasing complexities of “profes-
sionalization” in the early modern period. As surgeons and physicians alike
84 The Burdens of Disease

maneuvered for advantage (see Chapters Six and Ten), women practitioners
found themselves “gradually restricted to a role as subordinate and controlled
assistants in matters where, because of socially constructed notions of propriety,
men could not practice alone.”12 Within those roles, however, some women could
gain or retain considerable authority, as the career of Angélique Marguerite
Le Boursier du Coudray, the eighteenth-century French “King’s Midwife,”
illustrates.13 But much empirical practice remained outside the scope of the
established professions; at the end of the eighteenth century the midwife
Martha Ballard still performed a variety of healing services in Maine, despite
the growing power of organized (and male) professions.14

Physicians and Surgeons

By the late thirteenth century—earlier in some places—many medical
practitioners had established their formal qualifications as physicians. Those
qualifications might derive from possession of a university medical education
(which itself emerged with the general medieval university movement of the
twelfth century), from privileges granted by a public authority (lay or religious),
or from membership in a guild or “college” that had legal power to grant such
privileges to protect the standards of the healing trade. Some practitioners might
possess all three: the claims of others might be less clear.
Theoretically these “recognized” physicians practiced healing in accord with
their education, one dominated by Galen, Hippocrates, and a number of Arabic
texts based on classical authors. Physicians therefore believed that an imbalance
of humors resulted in sickness, for such imbalance led to an imbalance of the
qualities (hotness, dryness, and the like) that constituted each individual’s “com-
plexion.” Humors could be returned to balance by bleeding, scarifying, purging,
attention to diet that would restore the proper qualities, and medications that
might have the same effect. The physician’s armory included all those
approaches and remedies. In fact most physicians—most of whose patients
appeared with self-limiting or non-life-threatening conditions—usually offered
relatively gentle dietetic remedies that did not differ appreciably from those of
folk healers.15 That was equally true of medications, which for physician and
empiric alike might be drawn from a rich complex of local favorites, well-
established traditional herbals, and those derived from written classical sources.
“Magic” played some role in those medications, even for physicians.
From the late twelfth century on, surgery developed as a separate healing
skill, like medicine rooted in the written texts of antiquity. But while different
professional paths of physicians and surgeons developed, those lines were often
unclear, especially in Italy and southern Europe. While surgeons often did not
have the qualification of university education, both they and the physicians
“shared a common tradition of knowledge drawn from the same sources.”16
Continuity and Change 85

On the other side of the profession, surgery was also practiced by a continuum
of empirics, such as bonesetters, as well as by members of other guilds such as
barber-surgeons. Guilds of surgeons therefore sometimes found themselves in
conflict with rivals from both directions. But most agreed that the dressing of
wounds, the setting of broken bones, and such serious occasions as amputations
and lithotomies (to remove bladder stones) required a surgeon’s skills.

A large question remains: in this plethora of techniques and materials,
what was believed central to the cure? Did a herbal remedy, by itself, receive
credit for a physical effect on the body or on the disease? Were the words that
accompanied the remedy’s administration decisive? If so, did it matter who
uttered the words? Did the words have power apart from the speaker? Or was
the cure found in the person of the healer? How important was the preservation
of some symbol— a cross, an amulet, words written on a cloth and worn around
the neck—by the sufferer? The possibilities of belief, shading across a spectrum
involving more or less emphasis on some or all of the above answers, encom-
passed the worlds of physicians, surgeons, apothecaries, traditional folk healers,
priests, midwives, barbers, charlatans, magicians, and villagers with the “gift.”
If cures were “successful,” on what grounds do we explain the success? The
wide range of popular medicine certainly attracted masses of people throughout
the medieval and early modern periods. Far more sufferers repaired to popular
and folk healers—“wise women,” “cunning men”—than to orthodox physicians
who worked in the Galenic tradition. Some explanation of that relative popularity
lies in social and economic circumstances. Physicians—and to a lesser extent
surgeons and official apothecaries—were expensive, and village cunning men
and wise women were not. Outrageous charlatans who charged high fees did
exist, but they were relatively rare.
More important even than cost, however, was accessibility, both geographical
and social. Physicians were rare and overwhelmingly urban, in what remained (in
most of the Western world) a predominantly rural society. Village healers were
convenient. They also represented a familiar world, one of villagers from the same
social stratum, who shared common experiences and trials of life. However much
some folk healers wrapped themselves in arcane language and mystery, they
remained more familiar to most patients than the university-educated, urban,
pretentious physician. And village healers also offered, most frequently, gentle
healing arts: herbal remedies and baths (even if they insisted that the bath must
be taken in a stream flowing in a particular direction, or during a certain phase of
the moon). Contrast such therapy with the violent bleedings and purgings some-
times undertaken by the Galenic physician, or—worse yet—the ministrations of
the surgeon, offered with no anesthetic except alcohol or opium.
86 The Burdens of Disease

The activities of popular healers may also have appealed because they corre-
sponded to contemporary perceptions of illness and hence of cure. Such percep-
tions were, as Finucane puts it, often a “consensus of opinion,” as indeed they
are in all times and places.17 Medieval understanding of human anatomy and
physiology lacked much of the precision that it acquired in the centuries after
the sixteenth. “Causes” of disease bore no clear relation to cellular biology or
microorganisms; pathology related largely to externally observed symptoms.
Changes in condition, seen externally, might well be considered a “cure,” even
though they might (by modern lights) be temporary or partial or even a new and
more alarming stage of a disease. At the extreme limit of this “consensus of
opinion” lay contemporary views of death itself. Modern definitions of death have
become increasingly confused, as technology replaces failing organs; how many
contemporary laypeople still think (in good Aristotelian terms) that death occurs
when the heart stops beating? Well into the eighteenth century considerable
popular doubt persisted about when death occurred, dramatically illustrated
by the numerous cases of people hanged but later revived by their friends and
relations.18 Some medieval “miracles,” in which saints and their relics brought
the dead to life, might be explained by different definitions of death in the twelfth
and twenty-first centuries.
Many cures, of course, “worked” by any standard. The trial and error of
centuries of folk tradition had winnowed the vast field of herbal remedies. Still
other cures succeeded at least temporarily (or could be perceived as successful),
especially with the large variety of diseases that had remissive traits or that we
would, today, call “self-limiting.” The myriad viruses that produce colds and
influenzas usually run a limited course. We have already seen (in Chapter Two)
that scrofula’s remissive stages conferred on the kings of France and England
apparent power over that ailment.
And, perhaps most important of all, many popular cures “worked” because
the sufferers believed that they would. Disease ultimately is self-defined; psycho-
somatic symptoms are “real.” At least by the seventeenth century (and probably
much earlier) some healers knew the reality of the mind’s power over “disease.”
Keith Thomas quotes a fascinating example of such seventeenth-century

[A] French doctor had a patient who was convinced that he was possessed by
the Devil. The doctor called in a priest and a surgeon, meanwhile equipping
himself with a bag containing a live bat. The patient was told that it would take
a small operation to cure him. The priest offered up prayer, and the surgeon
made a small incision in the man’s side. Just as the cut was given, the doctor let
the bat fly into the room, crying, “Behold, there the devil is gone!” The man
believed it and was cured.19
Continuity and Change 87

Diverging Categories
In important and fundamental ways the responses of religion, medicine,
and folklore remained in a close and mutually supporting relationship over the
medieval and early modern centuries, and that relationship only began to founder
in the seventeenth century.20 Even then, the symbiosis did not rapidly dissolve;
rather it broke apart gradually and partially, in different times and places.
Religion’s connections with magic were considerable, but also always fraught
with tension. If in the high Middle Ages the Church brought “natural magic”
within its fold, in the same period it undertook a prolonged effort to regularize
popular religion and bring it under central control. The denunciation of numerous
local magical powers, cures, and shrines followed, as of course did more general
attacks on movements judged heretical. In addition, the elaborated theology of
the medieval Church attempted to clarify the limits of human powers to compel
nature to obedience. Cunning men and wise women might not clearly understand
those limits, and so could claim no theoretical support from organized religion.
The Protestant Reformation of the sixteenth century significantly widened
the gaps between religion and magic. Protestants simply dismissed the cults of
the saints as accretions that lacked scriptural authority. Even more fundamen-
tally, most Protestants refused to grant special powers to the priesthood.
Ordination was not a sacrament. And, in any case, for Protestants the sacraments
themselves lost their magical powers; for Calvin the Mass ceased to be a literal
reenactment of Christ’s sacrifice, in which wine was transsubstantially changed
to blood, and became instead a simple memorial service. The Christian religion,
at least in its Reformed guise, no longer had priests who performed miracles.
If religion was transformed in the early modern centuries, the world of
“magic” ultimately suffered particularly heavy blows. Intellectual and social
changes alike played roles in diminishing magic’s appeal. The Christian religion,
especially in its Protestant form, more clearly separated itself from “magic”; in
the short run, some historians have argued, magic flourished in sixteenth- and
seventeenth-century Protestant Europe precisely because orthodox religion had
left a vacuum for it to fill. Without saints’ shrines to repair to, sufferers turned all
the more readily to the “white witches,” the wise women and cunning men, the
benign faces of the contemporary “witch craze.” But in the longer term religion’s
antipathy turned opinion against the practitioners of magical healing, much as
rationalism ultimately dampened the ardor of witch-hunting.
Although religion and magic may have diverged, their difficulties with each
other paled before the challenges to both posed by new scientific beliefs. The
“scientific revolution” of the sixteenth and seventeenth centuries undercut tradi-
tional Christian orthodoxy and demanded new ideas about the relations of God,
nature, and humankind. And although the Renaissance naturalism that supported
some aspects of magic and empirical healing formed an important component of
88 The Burdens of Disease

the scientific revolution, other components that suggested a mechanical philo-

sophy of nature called that spirit-laden naturalism into question as well.

The Scientific Revolution

Medieval cosmology made it easy to believe that God’s power and prov-
idence totally dominated the universe, and that God had awarded man the spe-
cial central place in that universe. In fact the entire universe literally revolved
around humankind, which inhabited the stationary central sphere of the earth.
And while medieval people might regard the earth as a sinkhole into which the
universe’s corruption fell, the earth and its inhabitants were also clearly unique.
They occupied the central and privileged position, the stage on which the great
human and divine drama of salvation was played. Humankind capped God’s cre-
ation; sun, moon, stars all deferred to sinful man. How natural, then, to believe in
God’s providence, to believe in God’s constant intervention in human affairs, to
believe that individual sickness and health were the concerns and products of
the divine will. Between 1500 and 1700 belief in the salient features of that cos-
mology collapsed, to be replaced by quite different conceptions of the relation-
ship of God and man, and quite different explanations of the causes of natural
phenomena, including, ultimately, the causes of disease and health.
This story conventionally, and properly, begins with Copernicus (1473–1543),
who proposed, in effect, that the earth and the sun switch places, with the sun
taking the earth’s central place in the universe and the earth joining the other
planets and the stars in their revolution about it. The theory faced massive diffi-
culties before it could win general acceptance, for it removed the earth from its
privileged central position in the universe and hence posed grave psychological
barriers; even in the present century, people must be educated out of their
instinctive sense that the earth is central and motionless. It seemed to contradict
Scripture, inasmuch as Joshua had commanded the sun to stand still, which
implied that ordinarily it moved. And a moving earth demanded an entirely new
view of the motion of bodies, perhaps even a completely different mind-set.
Copernicus himself hardly addressed such issues at all.
Little wonder, then, that Copernicus’ ideas made few converts in the balance
of the sixteenth century. But in the hundred years after his book appeared, the
notion of heliocentricity both gained important adherents and underwent inter-
esting modifications. One was the gradual association of Copernicanism with the
radically new idea of an infinitely extended universe. Although this conception
was not found in Copernicus himself, he opened the door for it by his belief that
the universe was much larger than the prevailing cosmology maintained. By the
end of the century Giordano Bruno had advocated an infinite universe, without
any notion of a central place. Another interesting modification of Copernicus
Continuity and Change 89

came from Johannes Kepler (1572–1630), a German astronomer who argued that
the planets moved not in perfect unchanging circles—as both the Aristotelian
tradition and Copernicus had agreed—but instead followed elliptical paths
around the sun (for Kepler was in that sense a strong Copernican).
Kepler’s work led to precise laws of planetary motion, laws that made the case
for Copernicus more convincing from the standpoint of the connections between
astronomical theory and observation. And on a broader front the ideas of Galileo
Galilei (1564–1642) established the feasibility of Copernicanism as a physical
explanation; perhaps the earth really moved. Galileo began the construction of a
new science of motion that would explain the apparent anomalies that followed a
belief in the rotation of the earth. What caused the motions of the heavenly bod-
ies, and what caused the motions of bodies on earth? What kept the planets in
their courses around the sun, especially since—if Kepler was right—those
courses did not follow an unchanging circle? How to account for the heavy body
dropped from the tower, when the tower itself—if Copernicus was right—moved
in the “circle” characteristic of heavenly motions? Some seventeenth-century
thinkers believed that the causal question was secondary; better to ask how the
motion might be described mathematically? than to ask why the motion occurred.
Galileo and Kepler, for instance, both believed that the universe could best be
understood in mathematical terms. But questions of cause did not go away easily,
even for Galileo, Kepler, and others with their mathematical vision of nature. Two
broad physical interpretations of motion emerged in the course of the seventeenth
century. For some—most notably the great French philosopher René Descartes
(1596–1650) — motion arose from the mechanical interactions of matter. An
object moved because some other object pushed it. Others saw motion caused by
some natural “force” that could act at a distance, without objects being in direct
physical contact with one another. In this view natural objects had powers which
extended outwards. Thus while for Descartes the motions of the planets resulted
from the whirlpoollike pressure on them of a medium that filled all space, for
Kepler the planets were swept along by a force emanating from the sun.

Anatomy and Physiology

Regardless of the explanation of motion, these two schools of thought,
one mechanical and the other finding a perhaps-“vital” force in natural bodies,
had great influence in fields beyond cosmology and mechanics. Their impact
may be seen in both the chemical and the anatomical traditions of the scientific
revolution, two fields that ultimately bore on concepts of health and disease.
Challenges in those fields were associated with two contemporaries of
Copernicus: Paracelsus and Vesalius. Paracelsus certainly mounted the noisiest
and most immediately effective attack of the three; Vesalius was more deferen-
tial, but eventually similarly subversive of old ideas.
90 The Burdens of Disease

Galen’s authority in the fields of anatomy and physiology bolstered his author-
ity as a physician, and his physiological and anatomical ideas went largely unchal-
lenged until the sixteenth century. Although Andreas Vesalius (1514–1564) was,
like Copernicus, a reluctant revolutionary, he was a pivotal figure in a revolution
in thought nevertheless: a revolution that ultimately overthrew Galenic anatomy
and physiology.
Some groundwork for a challenge had been laid in the medieval period. For
one thing, thirteenth-century physicians and surgeons (in the universities of Italy
and southern France) resumed the practice of human dissection, a practice that
had been abandoned before Galen’s own time. In 1316, on the basis of this lim-
ited experience with the human frame, the leading medieval anatomy text was
composed: that of Mondino de Luzzi. Mondino’s text was copied and recopied
many times in the next two centuries, and for that period became the authority
through which an understanding of Galen was transmitted to students. Mondino
and others may have had direct experience of human anatomy, but Galen’s
authority led them to see the body through Galen’s eyes. If Galen said that the
stomach was a sphere, so did Mondino; if Galen said the liver had five lobes, so
did Mondino; if Galen said the heart had three ventricles, so did Mondino.
Before we condemn Mondino and his successors for slavish obedience to an
authority contradicted by their own eyes, we should remember the practical con-
straints on the practice of anatomy. One constraint was social: dissections per-
formed for the benefit of students were done not by physicians but by surgeons or
their assistants. The physician-professor sat at a high desk and read Mondino’s
text, while below in the pit the surgeon and his assistant worked away on the
cadaver. No necessary correspondence existed between what the professor read
and what the surgeon exposed. Another constraint was more difficult to avoid.
Dissection, though a regular practice, remained an infrequent one; the corpse was
often that of an executed criminal, for Christian resistance to such treatment of the
dead ran deep. Christians, after all, believed in the literal resurrection of the body.
Since corpses for dissection were therefore rare, each was precious for anatomical
instruction; the demonstrator used it all, as rapidly as he could, for there were no
effective means of preserving its organs. A demonstrative dissection might there-
fore be conducted hastily and carelessly.
Two other large barriers interfered with anatomical understanding. One was
the lack of agreed-upon terminology, and the other was the lack of accurate
reproductions of illustrations. Those difficulties began to be overcome in the fif-
teenth century, owing to changes in the worlds of scholarship and of art. The
humanism of the Renaissance was a complex phenomenon beyond our scope
here, but the humanists’ demands for pure Greek or Latin texts are relevant.
A “pure” text of Galen, for instance, would be “freed” of the Arabic and Christian
medieval barbarisms and word usages that interfered with understanding the
Continuity and Change 91

master’s meaning. Such arguments cleared the way for agreed-upon anatomical
terminology. Modern medical students may find committing anatomical terms
to memory an albatross, but imagine their distress if different professors had dif-
ferent terms for identical organs. Even more important, the rise of more natura-
listic artistic representation, when concentrated on anatomical detail, led to more
accurate illustration. And in the fifteenth century illustrations could be repro-
duced precisely, which for the transmission of anatomical knowledge was
absolutely crucial. Woodcuts and engravings, which existed by about 1400, came
into wide use by about 1450; etchings followed by about 1500. These techniques,
linked to the printing press developed by about 1450, made possible what
William Ivins called the “exactly repeatable pictorial statement,” important in
many aspects of modern civilization, of which anatomical illustration is one of
the most striking.21
By about 1500 some anatomists, notably Berengario, both became more criti-
cal of past authority and saw the possibilities of reproduced art for anatomical
instruction. Vesalius emphasized these new approaches. Andreas Vesalius, or
van Wesele, was born in Brussels, the son of an apothecary in the service of the
Hapsburg family. He received a physician’s education in the universities of Paris
and Padua, the leading centers of Aristotelian and Galenic learning of the age. At
Padua he passed quickly from student to master, and while attached to the fac-
ulty there he wrote his great textbook of anatomy. De humani corporis fabrica
(usually just called De fabrica) was published in 1543, the same year in which
Copernicus’ De revolutionibus proposed a heliocentric universe. Vesalius’ text
established for him a European reputation and led to his appointment as physi-
cian to the Emperor Charles V and subsequently to his son Philip II of Spain.
Vesalius died suddenly while returning from a trip to the Near East in 1564.
De fabrica, unlike De revolutionibus, did not set forth a challenging new general
hypothesis. In many ways it remained firmly in the Galenic tradition; its novelty lay
in its thoroughness, accuracy, and precise anatomical illustrations that approached
fine art. Vesalius shared most of Galen’s fundamental physiological assumptions
(see Chapter One): three different systems of vessels (veins, arteries, nerves)
based on three different organs (liver, heart, brain) moved different humors and
spirits throughout the body. But a critical spirit pervaded the work, and Vesalius
was eager and willing to find Galen’s mistakes. He especially delighted in showing
how Galen, by relying on dissections of animals other than humans, had been led
into anatomical errors in his descriptions of muscles and bones. Galen remained
the master, but the disciple proved his mettle by correcting the teacher.
This style of challenge persisted in what became a kind of “Vesalian” school
of anatomy in the university at Padua for the remainder of the sixteenth century.
Vesalius’ contemporaries and successors there continued to find and point out
Galenic errors of detail: Eustachi, Fallopio (both of them immortalized by the
92 The Burdens of Disease

names of body parts), Colombo, Fabrizio. And—crucial for the ultimate fate of
Galen’s system—some of the details became linchpins in a more general chal-
lenge to Galen’s authority. One of these details concerned Galen’s description of
the heart. Galen believed that the septum, the thick tissue that divides the heart
into right and left sides, was perforated by tiny pores that allowed some “venous”
blood to seep through from one side to the other. Vesalius could not detect those
pores, but—unwilling to challenge Galenic physiology—concluded: “Thus we
are compelled to astonishment at the industry of the Creator who causes the
blood to sweat through from the right ventricle into the left through passages
which escape our sight.”22 One of Vesalius’ successors, Colombo, proposed a
solution that would preserve the fundamental Galenic physiology. He traced
what is sometimes called the “lesser circulation” of the blood, in which the blood
passes from right ventricle to left auricle not through pores in the septum—
which are not there—but through the pulmonary artery, the lungs, and the pul-
monary vein. This transfer from one side of the heart to the other was very
important in Galen’s physiology, because arterial blood, which for Galen was
rooted in the heart, received much of its material (though not its essence) from
venous blood. By moving some venous blood to the left side of the heart,
Colombo “saved” the system, which otherwise would have been imperiled by
Vesalius’ failure to clearly confirm Galen’s necessary pores.
But the notion of a circulation, in which blood looped through the body from
one side of the heart to the other, proved a dangerous ally. Another Paduan
anatomist, Fabrizio of Aquapendente (or Fabricius), puzzled over another
anatomical detail: the so-called valves in the veins and their function. In Galen’s
physiology the flow of arterial blood, venous blood, and the fluid of the nerves
was in each case two-way; in the case of the veins, for example, venous blood
moved back and forth through them from the liver to the rest of the body, carry-
ing a fresh load of humors and spirits to all other organs, then returning to the
liver to be recharged. Fabrizio’s “valves” perhaps regulated the flow of venous
blood in some way. The door now opened for an inquiry that would be fatal to
Galenic physiology. One of Fabrizio’s students, the Englishman William Harvey
(1578–1657), used such details as the valves of the veins to propose an entirely
new system of human physiology in a book published in 1628: De motu cordis, a
masterpiece of experimental evidence, the use of dissection, quantification, and
analogical reasoning. Harvey put forward the general circulation of the blood, in
which blood moved from the heart through the arteries to the extremities of the
body, then returned to the heart through the veins. Fabrizio’s valves regulated
not volume of flow, but its direction; blood moved around the body in a grand
circuit, and not in an ebb and flow through three separate systems.
Harvey found at least some of his inspiration in Aristotle, for the Paduan
school that he represented had long been imbued with a careful Aristotelian
Continuity and Change 93

experimentalism. More than that, Harvey saw the human heart in fervent, near-
mystical terms, as the center of heat and life of the body; Aristotle had seen the
heart as the primary organ, a judgment that Galen’s tripartite systems had weak-
ened in favor of the brain and the liver, and that Harvey now restored. The blood
carried a vital principle of life around the body, one that regenerated the body
and gave it spirit. Thus although Harvey himself did not simply consider the
heart as a machine, a pump at the center of a hydraulic system, his doctrine of
circulation nevertheless invited such a mechanical idea. Seventeenth-century
thinkers were to find mechanical explanations of nature particularly convincing.

Paracelsus (1493–1541) is a major figure in the histories of both medi-
cine and chemistry, and his importance stems both from what he did and what
he was later thought to have done. Paracelsus, whose original name was
Theophrastus Bombastus von Hohenheim, was born in Einsiedeln, Switzerland,
the son of a man who practiced as a physician. When he was a boy his family
moved to Carinthia, where his father practiced medicine among the miners of
that province. The young Paracelsus’ education in medicine was apparently irreg-
ular; one writer calls it “inconsecutive,” meaning that it probably consisted partly
of apprenticeship and trial-and-error practice and partly of peripatetic attendance
at different universities. His enemies—and he accumulated a lot of them—
questioned his right to call himself a physician. He may for a time have practiced
as an army surgeon. By the mid-1520s he had developed a reputation as a healer.
Successful cures at Basel resulted in his appointment as official physician to that
Swiss city, where he made a great stir and after about a year had to flee the place.
On taking office in Basel he delivered an intemperate oration, often quoted since:

I am Theophrastus, and greater than those to whom you liken me; I am

Theophrastus, and in addition I am monarcha medicorum and I can prove to
you what you cannot prove. I will let Luther defend his cause and I will defend
my cause and I will defeat those of my colleagues who turn against me; and
this I shall do with the help of arcana. . . . It was not the constellations that
made me a physician; God made me. . . . I need not don a coat of mail or a buck-
ler against you, for you are not learned or experienced enough to refute even
one word of mine. I wish I could protect my bald head against the flies as effec-
tively as I can defend my monarchy. . . . I will not defend my monarchy with
empty talk, but with arcana. And I do not take my medicines from the apothe-
caries; their shops are but foul sculleries, from which comes nothing but foul
broths. As for you, you defend your kingdom with belly-crawling and flattery.
How long do you think this will last? . . . Let me tell you this: every little hair on
my neck knows more than you and all your scribes, and my shoe buckles are
94 The Burdens of Disease

more learned than your Galen and Avicenna, and my beard has more experience
than all your high colleges.23

Clearly a violent and radical character. After fleeing Basel, he wandered from
town to town in central Europe, in constant contention with medical establish-
ments. He wrote a great deal, but little of it was published before his death in
1541. He did, however, gain followers, who in the century after his death gave
his ideas—or what were said to be his ideas—greater and greater currency.
His writings were massively printed and reprinted between 1565 and 1620.
The varied history of Paracelsus and his work has meant that interpretations
of him have not been easy, and in any case Paracelsus’ thought is forbidding to
modern understanding. Some points are nevertheless clear. He systematically
(though not always consistently) denied the authority of the scholastics of the
Middle Ages, of Aristotle, and of Galen. He also proposed alternatives to those
authorities, but those proposals may be clearer if we first examine his criticisms
of established views. Just as Galen’s humoral medicine (and ultimately the
Hippocratic humoral medicine from which it came) was based on the theory of
the four elements, so too Paracelsus’ rejection of humoral medicine included a
rejection of those four elements, especially as they had been expounded by
Aristotle. Paracelsus was not entirely consistent about this, but in general he
argued for the primacy of what he called the “Three Principles” in place of the
Aristotelian quartet of earth, air, fire, and water. The three principles were sul-
fur, mercury, and salt; as with the Aristotelian four elements, the principles were
associated with certain physical qualities. Sulfur conferred on substances that
contained it the quality of combustibility; mercury conferred fluidity; salt con-
ferred solidity and color. Although some aspects of these ideas were not new—
Arabic thinkers had, for instance, emphasized the primacy of mercury and
sulfur—for Paracelsus they formed part of a sweeping attack on scholastic
authority, one with a true religious component and at least implied overtones of
social radicalism.
Part of Paracelsus’ denial of scholastic authority included a vigorous defense
of both “experiment” and “experience,” not necessarily the same thing although
some of their features overlapped. When Paracelsus asserted that “my beard has
more experience than all your high colleges,” the voice may have been that of
the practical man who had labored among the miners and soldiers, the man
whose dirty hands scorned mere book learning. But “experience” might also
mean that he had experienced something akin to revelation of divine mysteries,
and so had an arcane (remember arcana) understanding of, and perhaps even
control over, the forces of nature. Paracelsus, like many of the figures discussed
earlier in this chapter, certainly believed in nature’s occult powers. He was in
fact a leading exponent of that philosophy which imbued all nature with spirits
Continuity and Change 95

and souls, which made different natural phenomena the products of their own
self-willed principles of activity. “Experience” might mean the ability to penetrate
(or to have revealed) the secrets of that self-willed principle, to understand its
Paracelsus applied this notion of a self-willed nature to his thoughts about dis-
ease. He strongly disagreed with the Hippocratic-Galenic belief that disease was
a systemic malfunction. No, said Paracelsus, disease was local, not systemic; it
was the product of a disorder of a particular organ. Such disorders, it should be
noted, were chemical in character, and they illustrated that each organ had in
some manner its own will. Thus:

A person eating meat, wherein both poison and nourishment are contained,
deems everything good while he eats. For the poison lies hidden among the
good and there is nothing good among the poison. When thus the food, that is
to say the meat, reaches the stomach, the alchemist is ready and eliminates
that which is not conducive to the well-being of the body. This the alchemist
conveys to a special place, and the good where it belongs. This is as the Creator
ordained it. In this manner the body is taken care of so that no harm will befall
it from the poison which it takes in by eating, the poison being eliminated from
the body by the alchemist without man’s cooperation. Of such a nature are thus
virtue and power of the alchemist in man.24

When this “alchemist” (or as Paracelsus sometimes called it, this archaeus), an
independent self-willed spirit of a body organ, became incapacitated, disease
resulted. The physician should then become the substitute alchemist, correcting
the malfunctions by the administration of chemically prepared remedies.
Paracelsus also believed—as did many Renaissance thinkers, especially those
influenced by neo-Platonism—in the correspondences of the macrocosm and
the microcosm. The human body was a microcosmic representation of the
macrocosmic universe; events in one paralleled events in the other. Astral ema-
nations connected the two. The signs of one might be seen in the signs of the
other. Hence the importance of observation, not just of the body but of all nature,
for healing. Astronomical events were portentious for health, and so astrology
had a role; and the body was above all a microcosm of chemical processes, which
could be observed in the alchemist’s laboratory and then replicated in the body.
Book learning—or at least some sorts of book learning—was at a discount, and
the physician should gain experience with nature by working with it and observ-
ing it. And since the body’s actions (or more properly the actions of the
“alchemists” of the body) mirrored alchemical procedures, the physician must
be adept at such procedures, for they were the keys to maintaining health.
Paracelsus therefore emphasized the importance of medications prepared
96 The Burdens of Disease

in the laboratory, in addition to the herbals found in nature. We have already

(in Chapter Four) seen his advocacy of mercury compounds in the treatment of
syphilis, and we may now more clearly understand the philosophy that lay behind
that preference.
Paracelsus and his followers were largely responsible for a growing connec-
tion between medicine and chemistry in the period between roughly 1550 and
1700. In those years iatrochemistry, chemistry in the service of medicine, became
both a prominent medical philosophy and the great goal of practical alchemy;
the search for the transmutation of metals continued, but was often overshad-
owed by the practical composition of remedies used by physicians and by the
ancient search for the principles that would prolong life. Within the medical pro-
fession struggles went on between long-entrenched Galenists and the new
Paracelsians, or “iatrochemical” physicians. The struggle was especially bitter
and important in Paris, where the Galenists remained in control of the medical
faculty of the university but the Paracelsians enjoyed periods of favor at court.
These struggles had both religious and political overtones, for sixteenth-century
Paracelsians were apt to be associated with other “rebel” ideologies. Sometimes
the connections were more temperamental than ideological, but Paracelsianism’s
most basic beliefs had many conscious affiliations with Protestantism. Paracelsus
had founded a new science, purely “Christian” as opposed to scholastic, in which
truth was sought first in the Scriptures and then in God’s book of nature. Thus in
France, Paracelsian power at court coincided with the rise to power of the
ex-Huguenot Henry IV (1589–1610). In the late sixteenth century Paracelsians
often supported the new astronomy of Copernicus, not because they were per-
suaded by the astronomical evidence, but because here was another disagree-
ment with established scholastic authority, a disagreement that furthermore had
some of its roots in neo-Platonic philosophy.
From about 1600, neo-Paracelsian writings circulated more and more widely,
combining iatrochemistry with Paracelsian ideas about health and disease: anti-
Galenic, seeing disease as local, pro-“experience,” and self-consciously “Christian.”
At least some seventeenth-century healing practices were conducted in such
terms, in some cases by physicians thoroughly converted to Paracelsianism and
in some cases because aspects of iatrochemistry crept into even the most devout
Galenist’s armory. Connections grew between chemistry and pharmacology,
pushed along by Paracelsian influence. Pharmacopoeias appeared, inspired by
Paracelsianism. In the same spirit, a growing number of chemical texts concen-
trated on the preparation of remedies, emphasizing such procedures as
distillation and tests to judge the purity or composition of remedies. The text by
Jean Beguin, first published in 1610, went through forty-one editions in the suc-
ceeding eighty years; the text by Nicholas Lémery, which first appeared in 1675,
was still being reissued as late as 1757. It is a significant fact that in the age of the
Continuity and Change 97

scientific revolution the best-selling scientific works were not those of Galileo or
Newton but the chemical texts of Beguin and Lémery, found in the homes of
physicians and the shops of apothecaries all over Europe.
Paracelsianism did not simply mean more attention to chemical remedies,
however. In the seventeenth century it continued to embody an alternative and
sometimes revolutionary approach to nature. The Paracelsian philosophical tra-
dition was maintained most notably by Jean Baptiste van Helmont (1579–1644),
the most important seventeenth-century figure in what Allen Debus calls the
“Chemical Philosophy.” Van Helmont, like Vesalius a native of Brussels, became
a convert to Paracelsianism in the years after 1609 and spent the rest of his life
writing and arguing for the cause, as one of the most eminent physicians and
intellects of his age. Like Galileo, his ideas led him into difficulty with the Roman
Church, and he was placed under house arrest between 1634 and 1636. For van
Helmont religion intersected medicine in fundamental ways; the physician, he
said, had a “divine office.” In the Paracelsian tradition, he maintained that dis-
ease had a local, not a systemic, character. Both the organs of the body and the
diseases themselves possessed active, vital principles that combated each other.
The outcome of their interaction determined health, as the archaeus of disease
(outside the body) attempted to intrude its alien seed in an organ.
The remarkable controversy over the workings of the “weapon-salve”
illustrates aspects of Paracelsianism as they had emerged by van Helmont’s time.
The controversy arose within the Paracelsian belief that a healing salve could
be prepared that included blood from a wound, and that the salve should
then be placed on the weapon that had caused the wound. The resulting action-
at-a-distance, Paracelsians claimed, had a curative effect on the wound. Perhaps
this happened because of a magnetic action between weapon and wound; per-
haps, others such as van Helmont maintained, divine powers as well as magnet-
ism were at work. Notice that the efficacy of the cure did not enter the question;
at least until mid-century, Paracelsians took that for granted. Magnetism seemed
to Paracelsians an excellent example of sympathetic emanations and attractions
occurring across an apparently empty space, especially after William Gilbert thor-
oughly described magnetic effects in his De magnete (1600). Examples of such
emanations filled nature: did not flowers open and turn toward the sun?

Mechanical and Animate Forces

Thus two explanatory systems gained strength in the seventeenth cen-
tury, one explaining natural effects mechanically and the other invoking forces
acting across distances. While Paracelsians clearly supported the second, the
Vesalian tradition could lend aid to either or both. Harvey may not have been a
mechanical thinker, but his system of circulation could certainly be seen as
mechanical, with the heart a pump that forced fluid through conduits. Descartes,
98 The Burdens of Disease

imposing a mechanical interpretation on the heart, believed it the site of a fire:

blood, entering the heart, expands with heat and so pushes into the arterial sys-
tem; the “most agitated and penetrating parts of the blood” proceed to the brain,
setting off impulses in the nerves that ultimately cause muscular action.

This will hardly seem strange to those who know how many motions can be
produced in automata or machines which can be made by human industry,
although these automata employ very few wheels and other parts in compari-
son to the large number of bones, muscles, nerves, arteries, veins, and all the
other component parts of each animal. Such persons will therefore think of this
body as a machine created by the hand of God, and in consequence incompa-
rably better designed than any machine that can be invented by man.25

Seventeenth-century mechanical explanations of life found their most thorough

exponent in Alphonso Borelli (1608–1679), whose On the Motions of Animals
appeared in 1680, just after his death. Borelli subjected both body parts and ani-
mal functions to a searching mechanical examination; for Borelli the heart was
a piston that exerted a calculable force which kept the blood in circulation, and
the muscles and bones presented a tremendous complex of machines at work:
levers, pulleys, wedges.
But others invoked vital forces to explain life processes. Descartes himself,
the arch-mechanist, allowed that the possession of a “soul” differentiated humans
from other animals. Aside from the obvious influence and direction of
Paracelsianism and van Helmont, vital forces entered explanations of astronomy
and mechanics. Isaac Newton (1642–1727), the English thinker whose synthesis
dominated cosmology and mechanics throughout the eighteenth and nineteenth
centuries, ultimately appealed to “the very first Cause, which certainly is not
mechanical”;26 Newton’s gravitation could be described mathematically, but he
refused to see it as the product of Cartesian pushes and pulls among matter. He
argued that bodies could be, and were, moved by “certain active Principles,”
which caused gravitational, electrical, and magnetic effects and chemical
changes such as fermentation. Modern scholarship has now thoroughly
explored Newton’s alchemical beliefs. And if Newton—whose system suggested
to many eighteenth-century thinkers a universe that functioned as a gigantic,
perfect machine—saw vital forces in many physical phenomena, how much more
likely must those forces be in the biological world?

The Impact of the Scientific Revolution

The scientific revolution was not confined to the dramatic reconceptual-
izations of Copernicus, Kepler, Galileo, Harvey, and Newton. The authority of
the ancients underwent challenge from many quarters, often simply from floods
Continuity and Change 99

of new information. In the biological sciences especially, travel and discovery

presented new facts, as did the microscope, dramatically employed in the sec-
ond half of the seventeenth century. Anton van Leeuwenhoek began his system-
atic microscopic investigations in the 1670s, seeing the microorganisms he called
“wee beasties”; Jan Swammerdam used the microscope to support mechanistic
explanations of life, and described the subunits of blood called corpuscles; Robert
Hooke, in 1665, observed the microscopic structures of plants, which he called
“cells”; Marcello Malpighi, in 1661, traced the final links of Harvey’s circulatory
system by his microscopic examination of the capillaries. Biology and medicine
were caught in waves of enthusiasm for experiment and observation, which
included a rash of studies in comparative anatomy; the French architect-physician
Claude Perrault, who designed the east facade of the Louvre, died from an
infected wound received while dissecting a camel. Such discoveries—if not
Perrault’s— had a cumulatively weakening effect on the power of Aristotle and
Galen, as did the mere appearance of new forms of life and new remedies from
the newly found Americas. The use of cinchona bark as a specific treatment for
malaria, for example, cast Galenic remedies in the shade; so too did the growing
emphasis on chemically prepared remedies and salts favored by the Paracelsians.
The attacks on Galen—whether from Paracelsians, Harvey’s physiology, new
specific remedies, or comparative anatomy—formed part of a more general and
sweeping assault on the whole basis of Aristotelian philosophy. Important
philosophers in the early seventeenth century, especially Descartes and Francis
Bacon (1564–1626), came to the radical conclusion that all past knowledge was
uncertain and that the human mind must begin anew on different epistemologi-
cal principles, whether those of deductive reason and mathematics (as Descartes
urged) or of the inductive collection of data (as Bacon argued). In either case
authority— perhaps Aristotle’s, perhaps Galen’s, perhaps Christianity’s—must
be set aside.
By the end of the seventeenth century the scientific revolution had created a
picture of the universe startlingly different from that which had dominated previ-
ous centuries. The universe was now an infinite one, hence (by definition) cen-
terless, without a privileged position of the kind once occupied by the earth. The
earth was simply one of several planets of a sun, itself simply one of a great num-
ber of stars. All the universe acted in conformity with laws that described (with
mathematical precision) motions in a soulless geometric space. Man’s reason
had discovered these laws. What was God’s role? For Newton, who more than
anyone else had shaped this system, God’s presence was both everywhere and
necessary to the continuing functioning of the universe. But others—including
many who called themselves followers of Newton—came to regard God simply
as a great watchmaker, architect, or engineer, a being who designed a perfect
machine and then simply let it run. Voltaire, the great French writer, popularized
100 The Burdens of Disease

Newton in the eighteenth century and also poured contempt on the idea that
God’s providence could be bothered with the small details of earthly life and
death. By the end of the eighteenth century the French astronomer Laplace had
reduced Newton’s system to an entirely self-regulating mechanism; asked by
Napoleon to explain the role of God in his system, Laplace replied, “Sire, I have
no need of that hypothesis.”
Man’s relationship to God, therefore, underwent drastic change; the scientific
revolution placed great distance between humanity and God’s constant providence,
at least for the minority of the population numbered among the literati. Man’s
relationship to the rest of nature changed as well. Descartes, by rigorously insisting
on a division between “body” and “soul,” removed life and powers from matter.
Matter was inert; it moved only if something else pushed it; it had no self-willed prin-
ciple of activity. “Soul,” “spirit,” perhaps “mind” lay outside matter, observing it,
manipulating it, controlling it, but not part of it. Of course not everyone agreed;
Paracelsians certainly did not, for animating powers abounded in their universe.
But Cartesianism greatly assisted the notion that the human mind in some way
stood outside nature, able to observe it objectively and bend it to the human will.
That distance between humans and the rest of nature related in turn to the
new spirit in which nature was investigated. The belief grew that experiments
could be performed that would extend knowledge, not simply confirm already-
known truths; further, in the extension of knowledge lay the key to improving
humanity’s lot on earth. Confidence in man’s power over nature grew, and that
confidence included power over disease. Descartes again:

It is true that medicine at present contains little of such great value; but without
intending to belittle it, I am sure that everyone, even among those who follow
the profession, will admit that everything we know is almost nothing compared
with what remains to be discovered, and that we might rid ourselves of an infinity
of maladies of body as well as of mind, and perhaps also of the enfeeblement of
old age, if we had sufficient understanding of the causes from which these ills
arise and of all the remedies which nature has provided.27

Such optimism about human powers might make appeals to supernatural forces,
whether those of magic or religion, both unfounded and unnecessary.

Consequences for Healing Practices

Did the new science have much immediate effect on practices designed to
combat disease and promote health? The answer to that question has several lay-
ers, which relate to the professional position of healers, to the impact of different
new ideas, to the more general effect of the new world view, and to the relationship
between the new ideas and the social changes of the sixteenth and later centuries.
Continuity and Change 101

By the sixteenth century medicine stood as a dignified art, practiced by grad-

uates of medieval universities. In that century physicians moved in the direction
of tighter control over their privileges, forming corporations and “colleges” that
asserted such privileges and in some instances won legal recognition of those
privileges from governments. The social attitude of many physicians therefore
became more conservative, as their positions were buttressed by privilege that
they strongly defended. The education of physicians remained that of the
medieval university, with heavy emphasis on Galenism, however much
“Galenism” had been gradually modified since the thirteenth century. For propo-
nents of the new sciences, therefore, the physicians and their ideas stood as
attractive targets. An attack on Galen’s ideas—whether from the Paracelsian or
Vesalian quarter— furthermore might merge with other attacks by the new on
the old. Supporters of the Protestant Reformation might see Galenic medicine as
one of the products of the corrupt medieval centuries, when the Romish whore
grafted scholasticism onto simple Christian truth. The followers of Copernicanism
might see Galenist physicians as allied with Aristotelianism; more likely, the
opponents of Galenism, especially the Paracelsians, might become partisans of
Copernicanism. By the seventeenth century the use of vernacular languages
arose as another issue on which physicians might be assailed; Galileo wrote in
Italian, and Paracelsians in both England and France supported vernacular lan-
guage against Galenic, medieval, university Latin.
But physicians in general remained Latin, Galenic, and professionally privi-
leged, despite these assaults. Some new ideas had an effect on practice, but those
effects did not manifest themselves consistently or completely. Some physicians,
such as the “English Hippocrates” Thomas Sydenham (1624–1689), proclaimed
the supreme importance of clinical observation over theorizing, and then theo-
rized anyway. Harvey’s new physiology proved very convincing, but it made little
difference to therapeutics and no great impression on the continuance of
Galenism at the heart of medical education. Harvey, an Aristotelian physician
who wrote in Latin and enjoyed the privileges of his profession, did not find favor
with the Paracelsians and other iatrochemists, who showed only erratic concern
with the relations between physiology and medical practice. Iatrochemical ideas
certainly mattered more to therapeutics in the sixteenth and seventeenth cen-
turies. The advocacy of chemical remedies, many of them prepared from inor-
ganic substances, became an important result of the new science. Much
iatrochemical inspiration came from Paracelsus and his followers, but some
arose independently from practice that was consciously anti-Galenic and more
focused on “practical” remedies, whether botanical or chemical.
Paracelsians were often allied with Protestantism, as in the late sixteenth-
century court of Henry IV or with the English Puritans in the seventeenth. These
religious and political alliances at times gave rise to periods of unusual medical
102 The Burdens of Disease

activity. Charles Webster has shown how Baconian visions of a new medicine,
purged of the errors of antiquity, founded on observed truths, leading to a pro-
longed life in an ideal future, combined with Puritan theology in the revolution-
ary English decades between 1640 and 1660. A remarkable surge in medical
publications—and medical hopes—resulted.28 That was fine as long as the star
of Puritanism was in the political ascendant, but at other times the Protestant-
Paracelsian alliance might strengthen the world of the irregular healers dis-
cussed earlier. That great range of irregular healers, which in fact dominated the
world of practice in early modern Europe, also found common ground with
aspects of the new science. Protestants and Paracelsians alike called for a new
beginning that would involve an inner “experience,” and they urged the impor-
tance of “experiments,” whether spiritual or chemical. The Paracelsians and other
iatrochemists praised the importance of practice over theory and book learning;
furthermore, their doctrines shared many of the assumptions of the naturalism
that lay behind the wise women and the cunning men of folk medicine.
But in the long run, despite the apparent alliances between Paracelsians and
the world of folk healing, the scientific revolution dealt folk healers and their
allies a heavy blow. Much folk healing depended on a belief that the healer pos-
sessed, in some measure, the power to bend nature to his or her will, or at the
very least to be an able suppliant with nature. In the seventeenth century the sci-
entific revolution’s dominant thinkers established the idea that the natural world
was characterized by unvarying laws that could not be compelled by an individ-
ual. Spells, chants, and prayers could not stop the course of natural law; sickness
was no more subject to that sort of intervention than was gravitation. The scien-
tific revolution never won a complete victory over the folk healers; as we shall
see, folk traditions maintained a powerful hold in the Western world into the
twentieth century, and in some ways remained dominant into the nineteenth.
But the scientific model, and with it a different concept of “disease,” was now on
the board. Disease was no longer a punishment from God, escapable only by
manipulating the divine will, but a natural phenomenon like the tides against
which humans built dikes or the storms which humans kept out with a roof.
The scientific revolution also created a world of specialized learning, which
(even in its early decades) some of its adherents attempted to distance from vul-
gar popular misunderstandings. With the successful assertion of a “scientific
method” came new respect for knowledge gained through systematic observa-
tion, industrious experiment, and mathematical skill. These methods further
emphasized the virtues of public demonstration, reconfirmation by experiment,
in short verifiability, all antithetical to the practices of the village magi.
In the long run the new science became part of the currency of elite culture,
while “popular” culture adopted it only imperfectly, incompletely, and later.
Despite the efforts of a variety of popular lecturers and scientific societies, of
Continuity and Change 103

educational institutions, university core curricula, and autodidactic schemes,

“popular” understanding of the new science remained—and remains—incomplete.
Old ways persisted: the vast variety of rural customs and beliefs, the popular
recreations that contradicted the sobriety and diligence favored by the early
industrial pioneers, and—especially—the aspects of religion and “magic” that
symbolized “superstition” to the post-Enlightenment elite culture. Popular reli-
gious manifestations appeared at different times and places, with their enthusias-
tic preaching, their Pentecostalism, their prophecy, their faith healing. The
occult sciences kept their hold, or rather shifted their hold to an even broader
base in the population.
Even in the twenty-first century mass circulation newspapers still carry the
comforts of astrology to numbers—and even proportions—that would have
astonished Kepler. Spiritualism inspired both storefront practitioners and elite
Societies for Psychical Research. That the president of the United States was
reputedly guided through his calendar in the 1980s by astrology was both scan-
dalous to elite scientific culture and not very surprising.
So despite the scientific revolution, the position of what I have been loosely
calling “magic” has remained strong for at least some people in the Western
world. Since the seventeenth century, empirical healers have survived, even if
their connections with and rationalizations from the worlds of magic and religion
may have weakened. The costs of orthodox medicine remained high, the avail-
ability of physicians unpredictable. Official medicine, despite the new science,
only slowly offered superior therapy, and then only for some complaints.
Changes in the social circumstances of learning also occurred. Men of learn-
ing found new places in which to carry on their work. Learning, heavily clerical
in the Middle Ages, could now be found practiced by laymen in courts and in
universities alike. The seventeenth century also saw the foundation of a number
of scientific societies. Whatever motives lay behind these foundations, the scien-
tific societies of the seventeenth century symbolized new goals for a new intelli-
gentsia. Those goals were increasingly secular. They might be devoted to the
power of the state or to the wealth of commerce; they might also hope to provide
social legitimation for thinkers or to provide them with means of income. Both of
the latter goals would become more important in the eighteenth and nineteenth
centuries as men of science found themselves subjected to the whims of a mar-
ket economy. For those who provided health care to the population, several dif-
ferent changes might eventually flow. Medicine, like science, might come to be
seen in the interests of the state, as governments began to associate large and
healthy populations with their own potential power. The pressure of a free market,
in a literate society with growing disposable income, might bear on the monopolis-
tic privileges enjoyed by corporations of healers. The claims of religion, exerted
over both healing and the careers of healers, would weaken.
104 The Burdens of Disease

But while the economy of early modern Europe might have been moving in
the direction of a free market in which power would lie with consumers, the sci-
entific revolution also contributed to the strengthening of the closed elite of med-
icine. The successful assertion of a “scientific method,” at first most convincing
in the exact physical sciences, would eventually spread to the life sciences and
the healing arts as well. The prestige of the new science made it easier for med-
ical professionals to gain political privileges, conferred by states and organized
“opinion” alike. The practice of science was for those fortunate few with the time
and means to learn carefully and thoroughly, in what would eventually become
a prescribed and lengthy university curriculum. It was not for the unlettered vil-
lage wise woman, nor was it for the adept who awaited the revelation of truth
wrapped in dark mysteries. Science, and in the long run medicine, demanded
precise knowledge. Prominent figures of the scientific revolution denounced the
closed world of the scholastics and the dead hand of Galen, and so seemingly
allied themselves with new social and economic forces. But their legacy was
mixed. They created a new closed elite whose specialized knowledge immunized
it from the free market at a time when economic doctrine and practice pro-
claimed the virtues of a competitive society. The Western world’s approaches to
disease have been caught in the resulting tension ever since.

Disease and the


T he scientific revolution of the seventeenth century broadened in the

eighteenth into the European-wide current of thought and opinion called
the Enlightenment. The ideas, assumptions, and methods of the new science
spread to other realms of thought and culture. In the course of the
Enlightenment, healers adopted a few new approaches to specific diseases and
(more generally) showed the pervasive effects of the new scientific thinking. At
the same time some of the most important demographic developments in
Western history began. The West’s population began to rise, this time proceed-
ing unchecked by any epidemic-driven increase in death rates; this population
growth continued unchecked until birth rates slackened with the West’s indus-
trial maturity.
In fact the connection between the spread of the new science and the
eighteenth-century population breakthrough had more to do with environmental
change than with any medical intervention against disease. This chapter will
therefore first survey the early modern disease environment and the general
Enlightenment precepts that advocated (or effected) changes in it. Although
widespread agreement existed about such general points, the Enlightenment
was also a period of rapid change, lack of consensus, and even confusion in think-
ing about disease, its essence, and what should be done about it. The profes-
sional positions of healers, especially in times of dramatic political change,
reflected that uncertainty, as did Enlightenment responses to specific diseases
of importance to the time. A study of two diseases (against which eighteenth-
century thinkers made determined attacks) follows, and the chapter concludes
with another case which suggests that the triumph of Enlightenment was a very
mixed one.

106 The Burdens of Disease

The Early Modern Disease Environment

In many ways the disease environment of the Renaissance and early
modern Europe was a continuation of that established in the high and later
Middle Ages. Although major changes occurred in the years between 1350 and
1800, it is important to start with the continuities, because so much relative atten-
tion has been paid to the new features of the early modern scene. Western civi-
lization remained primarily rural until well into the nineteenth century; only in a
few places did urban life predominate. Most people remained, therefore, in areas
less likely to be affected by diseases of crowds, especially such airborne diseases
as tuberculosis, smallpox, measles, influenza, and diphtheria. To some extent
Western people remained isolated, as had their forebears in the early Middle
Ages; their diets might be subject to local famines and to the deficiencies of
heavy reliance on a few foods. Protein and iron deficiency remained common;
scurvy, beriberi, and rickets took seasonal tolls, certainly weakening if not
directly fatal. Ergotism presented recurrent problems, especially in damp sea-
sons and in marshy soils. Heavy outdoor labor with metal cutting tools brought
wounds, tetanus, and erysipelas. In all these respects the Western countryman
of the eighteenth century lived in much the same disease environment as his
seventh-century ancestor.
But in some respects the pace of change accelerated between 1450 and 1800.
Europe may still have been largely rural but its urban population grew, and more
cities could be found on more places on the map. Crowding was a fact of life—
and death—for a greater proportion of the populations of England, France, the
Iberian peninsula, and portions of Germany, as well as of Italy and the Low
Countries. Medieval Europe might have contained five cities (Paris, Venice,
Naples, Genoa, and Milan) whose populations exceeded 100,000; a dozen other
medieval places might have been called “urban.” Between 1500 and 1700 per-
haps twelve others (Antwerp, Amsterdam, Rome, Palermo, Seville, Lisbon,
Madrid, Messina, Marseilles, Vienna, and most dramatically London) passed
100,000, while the number of smaller cities had also multiplied in proportion.1
And perhaps more important than their actual total populations were the densi-
ties of settlement they represented. By the end of the eighteenth century the
City of London, an area within the old walls of about one square mile, contained
over 100,000 inhabitants. In 1990 Manhattan, the most thickly populated portion
of New York City, had a population density of about 67,000 per square mile in a
world of tall buildings made possible by electric elevators. No wonder that in the
intensely crowded conditions of the early modern city airborne diseases found
the critical mass of population they needed to sustain themselves; one estimate,
for instance, suggests that measles needs a population of 250,000 to maintain
itself.2 Whether early modern Western civilization really suffered from “new”
diseases or not remains a perhaps-unresolvable question, disturbed as it is by
Disease and the Enlightenment 107

perceptions and shifting terminologies and nosologies (systems of classification)

of disease; certainly many seventeenth- and eighteenth-century authorities said
that new diseases were among them. But if we leave the question of absolute
“newness” to one side, we may recognize instead that whether new or not many
epidemic diseases could flourish in early modern Europe more readily than they
could have in earlier centuries.
Of these the airborne diseases, especially tuberculosis, smallpox, and
influenza, became most important. But the crowded urban conditions also proba-
bly created more opportunities for those diseases dependent on fecal-oral trans-
mission. The conditions of water supply and sewage removal only changed for
the worse, for the increased populations of the cities continued to use rivers as
both sewers and sources of water. In the course of the seventeenth and eigh-
teenth centuries European attitudes toward bathing began to change, as cleanli-
ness of the body slowly gained recognition as a positive trait and bathing ceased
to be regarded primarily as a sensual experience. Nonetheless, the opportunities
for the spread of dysentery, diarrhea, and typhoid fever probably became more
frequent with the increasing urban population.
Health conditions in cities may have improved in other respects, however.
Some cities, especially those places within the sight of an enlightened prince’s
palace, began to benefit from stronger central planning and greater use of such
construction materials as stone, slate, and brick. London was massively rebuilt
with new materials in the wake of a disastrous 1666 fire. Such rebuilding and city
planning may have reduced some crowding, although city densities remained
very high. More important, and more likely, were reductions in contacts between
people and some disease vectors, particularly the fleas that brought plague and
the mosquitoes that brought malaria, and possibly also the lice that brought
typhus. Plague disappeared from much of the West in the eighteenth century
(see Chapter Three), and malaria’s position will receive further discussion later
in this chapter. But while new construction may have increased the space
between humans and vectors, or may have made less welcoming homes for
rodents and insects, the increasing frequency of European contacts with the
tropics—especially the “Indies”—brought countervailing risks from the rapid
dissemination of occasional imports such as yellow fever.
The disease environment of the early modern period also reflected important
changes in the character of European warfare. Through the seventeenth century
the technology of violence and the inability of rulers to control it combined to cre-
ate optimum conditions for the spread of disease. Battlefield wounds and their
resultant infections, perhaps accompanied by tetanus or erysipelas, increased
with the spread of firearms. Towns faced physical destruction from bombardment
and hence a collapse of whatever health and sanitation provisions might exist.
For a long time this new power remained to a great extent the privilege of those
108 The Burdens of Disease

with money, and much European violence and conquest inflicted on others was
controlled either by private interests or by states that hired private armies.
But states increasingly brought the new military technology under their
monopoly control, beginning in the seventeenth century and certainly by the
eighteenth. Sixteenth- and many seventeenth-century armies most often
remained shakily controlled by still-impoverished governments that sometimes
could not afford to pay them. They also remained basically unwashed and itiner-
ant, a powerful agent for the diffusion of diseases, of which typhus was the clas-
sic but hardly the only example. As the absolute monarchies (and some other
states) of the seventeenth and eighteenth centuries became more highly organ-
ized, a crucial element of their power lay in their better-disciplined armies; they
devoted a considerable amount of their resources to military power, sometimes
so much that taxes impoverished and weakened an already-frail class of the poor.
But the highly disciplined royal armies of the eighteenth century represented
less of a threat of anarchic violence and were less likely to diffuse typhus and
syphilis through the population.
Early modern social change held perhaps the greatest long-term significance
for the disease environment. Some of this change was rural, some urban, and
some resulted from the interactions between town and country. Agricultural
change, especially in northwestern Europe (the Low Countries and England,
spreading to portions of France and Germany), brought new crops and more
intensive cultivation of protein-bearing legumes. The wealth from that “agricul-
tural revolution” entered into a complex symbiosis with other economic forces,
especially the developing instruments of capitalism (credit, insurance) as they
related to Atlantic-based trade. By the eighteenth century (if not sooner) both
town and country in northwestern Europe partook of a market economy, one
that had the power to overcome the local famines and “subsistence crises” of an
earlier time.3 To some extent at least the roots of the modern industrial society
are found there, and that society ultimately adopted a different family structure
which, as Stephen Kunitz has argued, shaped a different disease environment.4
The impact of later marriages, smaller households, longer terms of breast feed-
ing, and declining agricultural labor by women, however, only became signifi-
cant in the nineteenth century.
And in the meantime agricultural change might not be an unmixed blessing.
Potatoes in much of central and eastern Europe (as well as Ireland) proved a rich
new source of calories, but encouraged a dangerous monoculture that allowed
the continuing exploitation of a farm labor population growing cash crops
for export that benefited landlords. Maize corn likewise brought calories to
southern and southeastern Europe, but also added another nutritional disease,
pellagra. From the seventeenth century into the nineteenth, the growing cities
of the Western world drew their population growth from migrants from the
Disease and the Enlightenment 109

surrounding rural lands, whose own populations were swelled by the stimulus of
these agricultural, social, and political changes. New generations of city dwellers
constantly appeared, whose immune systems lacked experience with the crowd
diseases raging in the cities. The growth and persistence of smallpox and tuber-
culosis as early modern problems may thus have been related to the social forces
creating “modernity.”

Enlightenment Conceptions of Disease

The thinkers of the European Enlightenment generally believed in the
importance of environment. Part of this conviction grew from their agreement
with the epistemology of the English philosopher John Locke, who (arguing
against Descartes) maintained that the human mind, a tabula rasa at birth, took
form under the impressions conveyed to it by the senses. The environment there-
fore shaped the mind. This doctrine pleased Enlightenment thinkers in part
because it implied the possibility of change. Original sin did not imprison human-
ity, if Locke was correct; the environment produced minds, so presumably a bet-
ter environment would produce a better mind, or a better character, or better
human institutions. The seventeenth-century conviction of the unaided powers
of human reason buttressed this optimistic credo. The human mind could stand
alone, without the reliance on authority (sacred or profane) that had previously
hampered it.
Eighteenth-century thought about disease partook of these general
Enlightenment principles. For several different reasons, Enlightenment thinkers
generally believed that the “environment” produced disease, although what
“environment” might mean varied considerably. For some diseases a “miasma”
was favored. This “bad air” doctrine often ran counter to established beliefs in
contagionism, and so contradicted the opinions that had slowly built up around
(especially) plague. In the seventeenth century many states had evolved elabo-
rate public health machinery to deal with the contagion of plague (see Chapter
Three), but in some eighteenth-century circles that machinery, and the thinking
behind it, fell from favor. In part miasmist opinion might have been more sympa-
thetically regarded by those Enlightenment thinkers who emphasized the rights
of individuals against the coercive powers of the state; in part contagionist argu-
ments also may have withered because plague ceased to be a major menace in
the eighteenth century, and that called into question the utility of the machinery
designed to divert it.
The miasma theory may also have been produced by the “new” diseases that
pressed in on Europeans. These new diseases included scurvy, syphilis, rickets,
and above all the “fevers” that by the eighteenth century bid fair to replace
plague as the object of greatest concern. “Fevers” might include typhus, malaria
110 The Burdens of Disease

(sometimes subsumed under a more general “ague”), yellow fever, and

influenza. Seventeenth-century thinkers produced a variety of causes for these
diseases, and while some remained familiarly medieval (divine wrath, plutonic
exhalations, unfortunate astrological conjunctions), mechanical and particularly
iatrochemical explanations came more to the fore.5
One of the dominant issues was the very “newness” of the disease. Could
descriptions of these complaints be found in the authorities of antiquity? If Galen
or Avicenna knew the disease, then their causes (and their remedies) might still
suffice. But if the diseases were genuinely new, did new pathogenic agents cause
them? The iatrochemist might see a new archaeus, while a mechanist might see
a change in the atmosphere, perhaps (particularly after the microscope opened a
new world of organisms) its pollution by tiny “worms,” as Athanasius Kircher
hypothesized about malaria. Mechanical explanations of that kind, applied in par-
ticular to the new fevers, might therefore focus attention on the environment.
This connection between the environment and human health, or human dis-
ease, found curious echoes in changing conceptions of human cleanliness and of
odors. In France at least, the use of water in bathing acquired associations with
health by the second half of the eighteenth century.6 In medieval thought baths
symbolized sensual pleasure, while in the sixteenth and seventeenth centuries
water was thought a positive hazard, which both opened the pores to invasion
and was associated (in bathhouses) with disruptions of public order. But in the
Enlightenment bathing with water came to have virtues. Cold water might con-
tract the body’s organs and thus harden or toughen them. More than that, water
might help banish the unhealthy smells and airs that caused disease. By the
1780s the unhealthy stenches of modern, especially urban, life—the odors of
cemeteries, rubbish, cesspools, and sewers—were under attack. Air had become
the health issue, the nose was a diagnostic tool, and clean water was the solution
to the filthy atmosphere that bred disease.7
Visions of human cleanliness, and thought about the “new” diseases, flowed
together with the general Enlightenment emphasis on the importance (and the
controllability) of the environment, creating a widespread climate for what James
Riley has seen as a demographically significant attack on the causes of mortality
and morbidity.8 Through advocacy of drainage, ventilation, lavation, and reinter-
ment, European thinkers (and in some cases governments) assailed many of the
vectors of disease without really knowing why their measures had an effect. Riley
makes a convincing case that opinion was strongly environmentalist; the effec-
tiveness of eighteenth-century environmental measures is harder to assess, if
only because so many variables intrude on any discussion of mortality and mor-
bidity statistics. Riley’s argument has another use, too, for it shows the complex-
ities of equating “contagionism” with “statism” and “environmentalism” with
“laissez faire.” Undoubtedly much liberal Enlightenment opinion resisted the
Disease and the Enlightenment 111

infringements on liberty that came with a contagionist doctrine; quarantines and

health passes were classic instruments of a heavy state hand.9 But other
Enlightenment thinking approved state action; the cameralist and mercantilist
state had enlightened supporters. And an attack on the environment might also
interfere with human freedoms. In addition, by the end of the eighteenth century
both thinkers and governments had developed a lively concern with the “popula-
tion problem,” which most often meant a fear that a state’s population was not
growing at the pace of its rivals. Public health, even in the eighteenth century,
might ultimately be justified by state power, which could take sustenance from
either “contagionist” or “miasmatic” interpretations of disease.

Nosology in Transition: “Fevers”

Thought about “fevers” had other ramifications. The seventeenth and
eighteenth centuries marked a period of transition in the ontological views of
disease. In medieval thought disease was primarily internal or, as Johanna Geyer-
Kordesch puts it, “a process unfolding within the definitions of how the body
works and functions.” In the nineteenth century, disease became “an entity gov-
erned by the laws of an unfolding reaction between microorganism and the
body.”10 Seventeenth- and eighteenth-century thinkers moved between those
poles. Did fevers represent particular, distinct, disease entities, or did they sim-
ply differ from one another (and from other, older fevers such as malaria) in
degree rather than in kind? At times, a seventeenth-century authority such as
Thomas Sydenham seemed to speak clearly about particular disease entities, but
he could also, as Lloyd Stevenson argues, characterize some fevers as more or
less gradations, modifications of a basic and generic “fever,” produced (in a
Galenic argument) by an unnatural source of body heat.11 Nosological schemes
became increasingly complicated. Hermann Boerhaave (1668–1738), the domi-
nant medical figure of his generation, employed both mechanical and iatrochem-
ical explanations in differentiating types of “fever.” William Cullen (1712–1790),
who enjoyed immense influence in the English-speaking world in his position at
the University of Edinburgh, attempted a new basis of simple classification, argu-
ing that all disease stemmed from the nervous system, which received (from the
environment) either too much stimulation or not enough.
In this increasingly eclectic and contentious discussion the notion of particular
disease entities made headway, partly because of the development of a particular
“specific” remedy for a specific fever. This was the bark of the cinchona bush, a
medication for malaria. Cinchona was one of several herbal remedies favored by
the Amerindians; their Spanish conquerors adopted it and brought it back to the
Old World. The Spaniards did not adopt all these herbs easily, for a variety of
“pagan” incantations and religious ceremonies accompanied their use. (In the six-
teenth and seventeenth centuries, for example, the Spaniards debated vigorously
112 The Burdens of Disease

whether they should encourage the use of coca as a stimulant that kept the
Peruvians at work or eradicate it as a symbol of blasphemous superstition and
anti-Christianity.)12 The Jesuits brought cinchona from Peru to Europe about
1630, and its use as a specific treatment for malaria spread despite another reli-
gious stigma, its association with the controversial missionaries who brought it.
Not every physician in Puritan England (for example) can have been happy to
prescribe “Jesuitical bark,” but even in Protestant states cinchona was widely used
by the late seventeenth century. Among the panoply of “fevers,” some responded
to cinchona and some did not. That fact gave weight to specific classifications.
Doubts remain about the effectiveness of cinchona, for some sort of “malaria”
remained a very serious problem in seventeenth- and eighteenth-century Europe.
Some areas had “malarial” reputations: the Camargue, the Loire Valley, the
Gironde in France; lowland Kent and Essex in England; the north German coast;
the Pontine marshes and the Po Valley in Italy; and the Don Delta in Ukraine, to
name only a few.13 Malaria repeatedly assailed those areas (as well as others)
through the eighteenth century; fevers devastated Brouage (at the mouth of the
Loire), and the marshlands of Kent and Essex were characterized by exceed-
ingly high mortality rates, in which burials regularly outstripped baptisms, until
the very end of the century.14 Even if cinchona had been widely used its effects
would have been most uneven, owing to the inconsistent quality of the material.
Bark, imported over a transoceanic distance, varied in its age and composition;
in addition, an effective dose required consumption of quantities that induced
vomiting. In 1820 the isolation of the active ingredient of cinchona, quinine, led
to more precise dosages and more effective therapy.

The Craze for Scientific Explanation

The Enlightenment placed vast faith in science, both as the source of
explanation and as the method for solving problems. The career of Franz Anton
Mesmer (1734–1815), while it lends itself to burlesque perhaps too easily, illus-
trates the conjunction of a number of different scientific currents of the century,
especially as those currents might relate to the healing of disease. Mesmer,
an Austrian physician, drew together ideas from both the mechanical and the
vitalist strands of the scientific revolution, and also employed the most exciting
sciences of the eighteenth century, chemistry and electricity.
Some of Mesmer’s appeal as a healer related to the traditions of the micro-
cosm and the macrocosm, and some to the pervasiveness of the ideas of Isaac
Newton in eighteenth-century culture. From the microcosm-macrocosm came
the notion of harmony between the body and the universe, a harmony necessary
for health. That harmony might involve the flow of “fluids” from macrocosm to
microcosm or vice versa, and the Newtonian philosophy gave a further scientific
imprimatur to belief in such fluids. Although Newton appeared to Enlightenment
Disease and the Enlightenment 113

thinkers as the perfecter of the great world machine, we should remember that
Newton (in his Opticks) also wondered: “Have not the small Particles of Bodies
certain Powers, Virtues, or Forces, by which they act at a distance?”15 And in his
great Principia, Newton wrote of a “certain most subtle spirit which pervades
and lies hid in all gross bodies; by the force and action of which spirit . . . all sen-
sation is excited, and the members of animal bodies move at the command of the
will, namely, by the vibrations of this spirit, mutually propagated along the solid
filaments of the nerves, from the outward organs of sense to the brain, and from
the brain into the muscles.”16
Much eighteenth-century thought about both electricity and chemistry rested
on those Newtonian speculations. Electricity seemed a certain manifestation of
such a subtle elastic fluid, pervading all nature and endowed with manifold and
exciting powers. Especially after about 1740, when the electrostatic generator
made static forms of electricity more accessible, electrical effects became a sta-
ple of popular scientific enlightenment and entertainment. Healers—for exam-
ple, Nicolas-Philippe Ledru, called Comus—seized on the mysterious fluid,
urging the curative powers of electric shock therapy. A number of other subtle
fluids caught the popular (and the learned) fancy as well. Magnetic effects illus-
trated one such powerful fluid. And chemistry, the other great popular scientific
attraction, contributed others. For a time the theory of phlogiston, advanced by
Georg Ernst Stahl, offered a general explanatory principle of chemical events.
Phlogiston, a subtle substance, entered into chemical combinations and pro-
duced changes, yet it had no discernible weight. Antoine Laurent Lavoisier, the
great French chemist who contributed much to the overthrow of the phlogiston
theory, retained a subtle weightless “caloric” as an elemental substance.
Newly discovered gases seemed yet another illustration of wonderful, elastic,
subtle fluids; balloons became, like lightning rods, symbols of the new sci-
ence. Gases, like electricity, might also have medical applications. Thomas
Beddoes, who lectured in chemistry at Oxford University between 1788 and
1792, became convinced of the medical utility of gases. In 1798 he opened his
Pneumatic Medical Institution near Bristol, where he and his assistant Humphry
Davy treated diseases (notably tuberculosis) with a variety of gases without
much result, although they did report on the interesting physiological effects of
nitrous oxide.
So when Franz Anton Mesmer began applying magnetic forces to heal bodily
ills in his Viennese practice in the 1770s, he represented widespread
Enlightenment beliefs and hopes. “Magnetism” might be mineral, related to lode-
stones; Mesmer was convinced that it could be “animal” as well. A subtle mag-
netic fluid exists everywhere in nature, and the health of the body depends on
the natural flow of this fluid through it. The physician should manipulate this
flow, reinforcing and directing it when necessary. In 1778 Mesmer moved to
114 The Burdens of Disease

Paris, the undoubted center of the Enlightenment world, and there his ideas and
his medical practice created a sensation. He positioned his patients around a
large tub filled with iron filings and bottles containing “mesmerized” water. Iron
rods connected the bottles to the patients, who thus received mesmerized mag-
netic fluids; they could apply the rods to afflicted body parts, or form a chain with
other patients around the tub, thus increasing the magnetic power with “animal”
magnetism as well as mineral.
All this was in line with the science of the day: subtle magnetic fluids, directed
and controlled for maximum effect on the body. Mesmer added other elements,
including powerful psychological suggestion. Robert Darnton describes the

Everything in Mesmer’s indoor clinic was designed to produce a crisis in the

patient. Heavy carpets, weird, astrological wall-decorations, and drawn curtains
shut him off from the outside world and muffled the occasional words, screams,
and bursts of hysterical laughter that broke the habitual heavy silence. Shafts
of fluid struck him constantly in the sombre light reflected by strategically
placed mirrors. Soft music . . . sent reinforced waves of fluid deep into his soul.
Every so often fellow patients collapsed, writhing on the floor, and were car-
ried by Antoine, the mesmerist-valet, into the crisis room; and if his spine still
failed to tingle, his hands to tremble, his hypochondria to quiver, Mesmer him-
self would approach, dressed in a lilac taffeta robe, and drill fluid into the patient
from his hands, his imperial eye, and his mesmerized wand.17

These methods resulted in some spectacular cures; Mesmer was enriched by

his Parisian practice, and by 1789 the Mesmerist Society of Universal Harmony
had branch chapters in two dozen French provincial cities.
Darnton has convincingly shown that political issues were involved in this
healing craze, as well as scientific and autosuggestive ones. Mesmer’s merits
divided established French science from the moment he appeared. The Royal
Academy of Sciences and the Royal Society of Medicine both opposed his claims,
but some of the medical faculty at the University of Paris came to his defense.
Disgruntled intellectuals on the fringes of the establishment took up causes such
as Mesmer’s as their own, seeing in him a man of truth and ability whose merits,
like theirs, had not been recognized by the elite ranks. The royal government,
alarmed by the conjunction of radical science and radical politics, attacked
Mesmer’s scientific credibility, and a prestigious commission was formed for
that purpose that included Lavoisier, Benjamin Franklin, and Jean-Sylvain Bailly,
later to be a prominent (though moderate) revolutionist. The commission’s
experiments (1784) ridiculed Mesmer’s claims, but by then Mesmer had become
a symbol of political liberty and (more important) popular culture and belief apart
from the dictates of elite science. Mesmerism survived in part because its cures
Disease and the Enlightenment 115

satisfied many patients, but perhaps also because it appealed as an alternative to

official medicine.
What had begun, with Mesmer, as science in the service of healing had
become a branch of popular antiscientific culture. Although in the course of the
nineteenth century mesmerism became more and more closely associated with
spiritualism and hypnosis, a large healing element remained in it. And not all
the scientific cure enthusiasms of the eighteenth century finished as parts of a
counterculture. Some others forced their way into the training and practice of
orthodox medicine and surgery.

Evolution or Revolution?
By the end of the eighteenth century many of the traditional ideas and
practices of orthodox medicine had come under question or evolved away from
their roots. Although some historians, notably Erwin Ackerknecht and David
Vess, have emphasized the sudden changes caused—or at least precipitated—
by the great French Revolution that began in the 1780s, others have convinc-
ingly argued that the medical changes of the revolutionary period in France were
more evolutionary in character, and that much of the “new” of that period was
not new at all.18 The humoral medical traditions of the ancients had been widely
criticized since the sixteenth century, and while a single dominant paradigm had
not replaced them, they no longer commanded general assent. The professional
divisions between physicians and surgeons had steadily eroded, and with them
the exclusively literary education of one and the exclusively apprentice training
of the other. And medicine gradually spawned specializations. These trends were
all clearly under way before the French Revolution, however much events in that
great upheaval may have accelerated them.
Although it may be possible to argue, in Stevenson’s words, that new seven-
teenth-century thinking about disease “exhibit[ed] conventionality of an antique
pattern” eventually the eighteenth century conceived of disease in new terms.19
Did calling a patient “scorbutic” differ, Stevenson wonders, from calling him
“splenetic”? Perhaps not. But for seventeenth- and eighteenth-century thinkers,
scurvy became a separate disease, not a variant on a continuum of splenetic dis-
orders. Specific fevers came to be seen as amenable to the specific remedy of
cinchona. Particular mechanical or chemical causes came to be seen as respon-
sible for particular diseases. Even insanity, where the hold of religious or folk
explanation was especially strong, came to be seen as a separate disease, with
chemical or mechanical explanations related to the nerves.
Some medical education emphasized the new views. At Edinburgh, especially
during the teaching of Alexander Monro secundus after about 1760, medical train-
ing shifted from a systemic view of disease to one that placed more emphasis on
disease’s particular and local character. This localist approach could be found in
116 The Burdens of Disease

medical teaching in London, Copenhagen, Berlin, and Vienna as well. If disease

was studied as a discrete series of local manifestations, it was therefore not a
phenomenon of the humors that systemically coursed through the entire frame.
So when the French Revolution began, a local and particular view of disease
was already at large. Philippe Pinel (1745–1826), an especially influential physi-
cian of the Revolution, was an antihumoralist, but still believed in classifying dis-
ease on a continuum, according to symptoms. The next generation of French
thinkers, during the Revolution, broke away from that view entirely. Xavier
Bichat (1771–1802) insisted on the completely local character of disease, which
he located in the solid tissues of the body as opposed to the fluids carried
throughout the system. François Broussais (1772–1838), a student of Pinel and
Bichat, argued the case for local disease even more enthusiastically; when the
solid tissues of the body, nourished by digestion and respiration, were over- or
understimulated, disease resulted. Since stimulus was largely digestive,
Broussais traced most disease back to the digestive tract. (Curiously Broussais,
the great opponent of systemic humoral medicine, advocated a thoroughly
humoral therapy: bleeding, to drain the overstimulated solid tissue. Under
Broussais’s influence French physicians in the 1820s and 1830s prescribed a
phenomenal number of leeches for their patients.)
The growing strength of the local view of disease related not only to the
progessive weakening of Galen but to the changing professional positions and
educations of physicians and surgeons. Traditionally physicians had received a
university education that emphasized ancient learning; surgeons, less genteel,
had entered an apprenticeship that emphasized manual techniques. In the eigh-
teenth century (at least in some places) the divisions between the two began to
shrink. Surgeons slowly rose in professional esteem. In France they became
more formally organized, with their own collegiate guild, while the meaningful
division in French healing practice ceased to be between physicians and sur-
geons and became that between successful and unsuccessful practitioners.20 In
England the surgeons also rose in status, and in wealth as well.
At the same time the educations of the two moved closer together. Schooling
as well as apprenticeship was required of French surgeons from 1772 on. At
Edinburgh the medical education of physicians came to emphasize clinical train-
ing as early as the time of Alexander Monro primus beginning in the 1720s; in
the period of his son lectures were given to medical students and surgical appren-
tices simultaneously. In London the anatomical school of John Hunter
(1728–1793) was only the most famous of a collection of private facilities that
taught would-be physicians and surgeons alike. With this increasing emphasis
on clinical training for physicians came a looser connection with the systemic
Galenic tradition and a closer connection between the world of the doctor and
the hospital, where pathological experience could be found in its greatest
Disease and the Enlightenment 117

diversity. Although London physicians, in the words of William Bynum, came to

see hospital connections as “useful” originally because of the social and profes-
sional contacts they offered, once in the hospital the physicians might see its
connection with clinical learning more clearly.21
Recent historical writing has argued that many of these changes, especially
as they occurred in the “Atlantic” worlds of western Europe and North America,
were driven by the entrepreneurial character of those societies. Roy Porter
(speaking of Britain) and Matthew Ramsey (speaking of France) have pictured
worlds in which clients—patients—dominated their relations with healers.22
Thus the power of old monopolies and corporations was savaged, and patients
patronized whatever “worked” for them (however “worked” may be defined).
Thus surgeons, midwives, apothecaries, and a wide range of irregular and folk
practitioners might flourish, regardless of their qualifications. This entrepre-
neurial climate also affected the education of healers. Especially in London,
competitive private enterprise drove anatomical schools; the Hunters’ school
succeeded because it offered better teaching, the prestige of the teachers’
research, and their evident (and conspicuous) monetary rewards. The demands
of clients may also have furthered still another eighteenth-century trend: that
toward medical specialization, to be discussed shortly.
Intellectual factors, as well as sociological or economic ones, contributed to
the linkages of surgeons, physicians, and hospitals. The same Enlightenment
doctrine that urged the importance of the environment also stressed learning by
the direct experience of the senses. Locke and his French disciple Condillac had
made that point. Pierre Cabanis (1757–1808), a physician and idéologue who
enjoyed much influence in the revolutionary years, carried it into the medical
world. For Cabanis experience and observation were the keys to medical learn-
ing; the French Revolution, founding new medical schools on that principle, car-
ried out a well-established Enlightenment doctrine in doing so.
The Revolution, determining that past educational systems had created a soci-
ety filled with error and superstition, swept all the old educational institutions
away and created (at least in theory) a wholly new structure. Medical education
was not exempt. In 1792–1794, the peak period of revolutionary fervor, medical
universities and institutions were abolished together with the old distinctions
between regular and irregular medicine. In 1794 the chemist Fourcroy (himself
an active revolutionist) submitted a report to the National Convention that urged
the complete reformation of medical education:

In the Ecole de Santé [the new medical school] manipulation will be united
with theoretical precepts. The students will do chemical exercises, dissections,
operations, and bandaging. Little reading, much seeing, and much doing will
be the foundation of the new teaching which your committee suggests.
118 The Burdens of Disease

Practicing the art, observing at the bedside, all that was missing, will now be
the principal part of instruction.23

Fourcroy’s rhetoric, addressed to a revolutionary assembly, obscured the extent

to which his proposals had already begun to be implemented in European med-
ical training before 1789. But the Convention, impressed, decreed that new
medical schools were to be opened on these “practical” principles in Paris,
Strasbourg, and Montpellier. In subsequent years hospitals were revamped,
more hospitals opened, overcrowding reduced, and hospitals began developing
specializations that both contributed to clinical teaching and to the idea of sepa-
rate disease entities. Some of this occurred under the prodding of the Napoleonic
minister Jean Chaptal (1756–1832), another chemist. In 1803 the government,
now that of Napoleon’s Consulate, took its most significant step when it provided
for a uniform state licensing system for physicians and surgeons alike; each was
now required to complete four years of medical education and then a state exam-
ination. All the old regional monopolies and corporations were abolished, and a
clear line was thus drawn between “regular” medical practice and all others. The
implications of this for the host of irregular practitioners were considerable (see
Chapter Ten).
The period of the Revolution also sped the specialization of French medicine,
although the Revolution itself can hardly be made the sole agent for such a broad
change. In part specializations emerged from greater knowledge; in part more
specialized diagnostic technology (such as the stethoscope, invented almost
serendipitously by Laënnec in 1816) made them possible; in part the growth of
hospital practice, in large cities that generated a volume of cases, made them
professionally feasible; and in part they developed because practitioners and
patients alike preferred them. The last point was probably important, especially
if the eighteenth and early nineteenth centuries were really periods of wild entre-
preneurial competition.
Concepts of disease furthered specialization as well. If a disease came to be
conceived as a separate entity, it might be amenable to treatment by a separately
trained specialist; if disease was a local phenomenon, confined to one organ of
the body, the same reasoning applied. In any case, separate hospitals for vene-
real disease emerged in the 1780s, for pediatrics in Paris in 1795, and for derma-
tology in Paris in 1801, while psychiatry was another clearly developing specialty.
Psychiatry’s evolution has been particularly seized upon by Michel Foucault,
for whom it became a paradigm of modern civilization’s gaze.24 The state (and
institutions related to it) disciplines its populations by placing them under contin-
uous observation and restraint, first and most obviously in prisons and asylums,
then in clinics of all sorts, and finally in the insidious collection of information in
the modern computer age. Foucault’s ideas, as a whole generation of thinkers
Disease and the Enlightenment 119

has now said, have been immensely influential, and their insights have illumi-
nated much thought about disease. Whether the history of Western care of the
“insane” can be as neatly categorized as Foucault wanted to do remains dubious,
however. Madness called forth a wide variety of responses, theories, and treat-
ments, and behind those treatments lay a messy collection of motives.
In brief, the eighteenth-century conceptions of madness tended to veer away
from traditional ideas, either those based on religion (possession by devils, or
religious melancholy) or those associated with humoral imbalances. Instead
“scientific” thinkers associated madness with chemical or mechanical causes,
especially involving the digestive or nervous systems. Enlightenment thinkers
also, not surprisingly, believed in the importance of the social environment.
These secular explanations, whether scientific or social, gradually led to differ-
ent conceptions of the mad, and to different possible approaches to their care.
Madness was less often equated with evil or with bestiality; the mad were now
conceived as victims, perhaps as children, and the conviction slowly took hold
that a cure was possible. Reasons for confining the insane became increasingly
complex. Earlier rationales—locking up the dangerous for safekeeping—became
mixed with confinement for cure, confinement of those thought nuisances or
embarrassments, or (as Foucault emphasized) confinement of the poor, women,
and the social victims of modern industrial life. Confusing the issue of rationale
still further (especially in Britain) was free enterprise; some of the insane were
evidently wrongfully incarcerated by entrepreneurs who profited from their
“care.” As Roy Porter has skillfully shown to be true in Britain, these responses
could all be found in the eighteenth and early nineteenth centuries, with consid-
erable local variations and almost no “central” direction at all, so that there at
least Foucault’s sudden imposition of an all-seeing gaze by central authority did
not occur.25 In any case, however, care of the insane increasingly came to be
seen as a medical problem, in which some hopes might be held out for a recov-
ery: perhaps after application of some remedy, such as opium, chemical prepara-
tions, or electric shocks; perhaps after expert “management” of the patient by a
doctor specializing in madness, such as Francis Willis, who treated George III of
Great Britain in 1788 and 1789.

The Enlightenment Attacks Disease

Smallpox and scurvy attracted considerable European attention in the
century, and Enlightenment responses to them illustrate the workings of the new
science, at once experimental in method and optimistically ameliorative in spirit.

Smallpox has apparently been eradicated as a human disease. Its last
reported case occurred in Somalia in 1977, and in 1979 the World Health
120 The Burdens of Disease

Organization officially announced its disappearance. The conquest of smallpox

remains one of the most dramatic episodes in humanity’s confrontations with
disease. The roots of smallpox eradication are found in the eighteenth century,
and the history of smallpox in that period occupies an obviously central place in
the relations between disease and the people of the Enlightenment.
Smallpox, a common childhood disease to medieval Europeans, became inex-
plicably serious for them in the second half of the sixteenth century. At that point
smallpox, often in combination with measles, began a series of grim visitations,
much more frequent than its occasional serious earlier outbreaks: several thou-
sand children dead in Naples in 1544, an epidemic in Rome in 1569, ten thousand
dead in Venice in 1570–71, and numerous contemporary reports from other
European places as well, some of them not offering clear diagnoses of the differ-
ent causes of death. Evidence from the seventeenth century was clearer, particu-
larly from the well-studied London “Bills of Mortality.” Ann Carmichael and
Arthur Silverstein have shown that those data present a “continually increasing
annual background level of smallpox’s contribution to total mortality from 1629
onward”; by the end of the century smallpox accounted for about 5 percent of
London deaths, a proportion that rose to as much as 12 percent in epidemic years
such as 1634, 1649, 1652, 1655, 1659, 1664, 1668, and 1674.26 That pattern, some-
what stabilized, persisted into the eighteenth century: a steady 5 percent of
all deaths were caused by smallpox, the percentage rising in the frequent
Children accounted for a high proportion of the deaths; smallpox caused per-
haps one-third of all childhood deaths in seventeenth- and eighteenth-century
Europe. The incidence of smallpox was very high as well, although morbidity
figures are even less certain than those for mortality. In the English town of
Chester in 1774, about 1,200 cases of smallpox were reported in a population
of 14,700; the investigator, John Haygarth, believed that most of the rest of
Chester’s population had already had smallpox. Of the 1,200 sick in Chester, 202
died, probably a typical eighteenth-century mortality rate, although in some epi-
demics that figure might have been considerably higher.27
As several historians of smallpox have noted, the disease did not respect rank.
Smallpox fatalities repeatedly interrupted reigns and successions. Balthazar
Carlos, heir to the throne of Spain, succumbed to smallpox in 1646; his death
led to the succession of his half-brother Charles II, feeble in both mind and
body, the last Spanish Hapsburg. When William II, prince of Orange and
stadtholder of the Netherlands, died of smallpox in 1650, the decentralizing aris-
tocracy returned to power in that country and no new stadtholder was chosen
until 1672. The death in 1700 of William of Gloucester, sole surviving son of Anne
Stuart, stimulated (together with his mother’s impending succession to the
English throne) the constitutionally significant Act of Succession of 1701.
Disease and the Enlightenment 121

The death of Luis I of Spain, in 1724, led to the reassumption of the throne by his
father Philip V, who had earlier abdicated. Other notable smallpox deaths
included those of Mary II of England (1694); Louis, son and heir of Louis XIV of
France (1711); Joseph I, Holy Roman Emperor (1711); Peter II, czar of Russia
(1730); Ulrica, co-regent of Sweden (1741); and Louis XV of France (1774). This
grim royal chronology illustrates the hold that smallpox had established in
Europe by the early eighteenth century.28
Smallpox killed, but it also disfigured those who survived it. Seventeenth- and
eighteenth-century narratives recount, over and over again, the sad stories of
scarred beauty and shattered romance. Poets from the early seventeenth to the
late eighteenth century moralized in terms that changed little from Ben Jonson

Envious and foule Disease, could there not be

One beautie in an Age, and free from thee?
. . . Thought’st thou in disgrace
Of Beautie, so to nullify a face,
That heaven should make no more; or should amisse,
Make all hereafter, had’st thou ruin’d this?29

to Oliver Goldsmith (1760):

Lo, the smallpox with horrid glare

Levelled its terrors at the fair;
And rifling every youthful grace,
Left but the remnant of a face.30

A virus, Variola major, produced this terror. The virus is one of a group called
orthopox viruses, which affect a variety of mammals including cows and mon-
keys with diseases called (obviously enough) cowpox, monkeypox, and the like.
The viruses are separate species, biologically distinct, within the genus of
orthopox viruses, but immunities to them overlap. Three of these viruses pro-
duce differing forms of smallpox in humans. Variola major results in a serious
disease, whose results we have seen in America and then Europe. Variola minor,
much less lethal, causes death in only about 1 percent of its victims. The distinc-
tion between these two forms of one disease was only recognized in the late nine-
teenth century. The third form, Variola intermedius, producing (as its name
suggests) an illness intermediate in severity between the other two, was first dis-
tinguished in 1965. The smallpox viruses, while distinct species, are antigeni-
cally identical. The existence of the Variola minor form calls into doubt much of
the early history of the disease, if only because a case of Variola minor smallpox
might not have been clinically recognized as smallpox.
122 The Burdens of Disease

Because smallpox is an acute disease, exposure to one form of it confers

immunity from subsequent attacks by all the others, and that fact—not perceived
in those precise terms—lay behind very early attempts at smallpox prevention.
Apparently the practice of inoculation, or variolation, for smallpox began in some
misty folk antiquity, the product of empirical wisdom. By the sixteenth century
descriptions of the procedure began appearing in Chinese medical texts, and in
seventeenth-century China the imperial court sponsored experimental trials of
it.31 The pus from smallpox lesions was extracted and placed—perhaps directly
in the nostrils or in the skin by scarification—in the body of the person to be
inoculated. A mild case of the disease resulted, or so the inoculator who per-
formed the operation hoped; the inoculated person then enjoyed immunity from
further attacks. Certainly medieval and early modern Europeans (at least until
the early seventeenth century) deliberately exposed their children to smallpox
victims, in the belief that, as many medical authorities argued, smallpox was a
natural or even beneficial stage in the maturation process. With that theoretical
background, it would not be surprising if some Europeans hastened the coming
of smallpox by the practice of inoculation; although the documentation of
European inoculation before the eighteenth century is scanty, reports of the prac-
tice have been found from the British Isles to Greece. African slaves may have
brought the technique to the Americas.
But only in the eighteenth century did the folk practice of inoculation gain the
attention of learned Europeans. By that time smallpox had long ceased to be a
childhood annoyance and had become a first-rate scourge. Accounts of Asian
practices of inoculation appeared in scientific publications in the early years of the
century, notably the communication from a Greek physician, Timoni, in the
Philosophical Transactions of London’s Royal Society in 1714. Shortly thereafter
the practice came under the large and expanding umbrella of experiment and nat-
ural curiosity that characterized eighteenth-century elite culture. Inoculation
established its first formal beachhead in England, where it benefited from the
patronage of important people: Hans Sloane (1660–1753), fashionable physician;
Lady Mary Wortley Montagu (1689–1762), an aristocrat who had herself suffered
from smallpox and determined to spare her children and friends from its ravages;
and some members of the new Hanoverian dynasty, perhaps with a wary eye on
the extinction of their Stuart predecessors. Montagu, resident in Constantinople
with her diplomat husband, heard of empiric inoculation in that city:

There is a set of old women who make it their business to perform the operation
every autumn, in the month of September, when the great heat is abated. People
send to one another to know if any of their family has a mind to have the
smallpox: they make up parties for this purpose. . . . The French Ambassador
says very pleasantly that they take up the smallpox here by way of diversion,
as they take the water in other countries.32
Disease and the Enlightenment 123

Thus reassured, Montagu submitted her son to the procedure and reported its
success to her London correspondents.
Sloane and the surgeon Charles Maitland (who performed the first docu-
mented inoculation in England in 1721) persuaded Caroline, Princess of Wales,
of the merits of the operation. Experiments followed, at the court’s behest, in
which six condemned criminals agreed to submit to inoculation in return for
their freedom. Unlike the Tuskegee syphilis experiments of the twentieth cen-
tury, this early example of medical trials on the socially marginal may actually
have benefited the subjects, for five of the six criminals easily recovered from
the mild cases thus induced, while the sixth showed no symptoms at all, leading
to the suspicion that he had already had the disease. A further successful test fol-
lowed on six orphaned children (another powerless population), and then
Princess Caroline, her fears of the obvious dangers relieved, acceded to the vari-
olation of her own children.
This royal patronage set off a brief craze for inoculation in England in the
1720s, but several well-publicized deaths following the procedure added strength
to the arguments of opponents. By the end of the decade those arguments, which
embodied some mixture of fear of danger, professional caution of physicians
fearful for their reputations, and religious worries that inoculation interfered with
the will of God, combined to drive out the fad. Meanwhile advocates of variola-
tion had also practiced the art in British North America, notably in Boston, where
the Puritan divine Cotton Mather added his formidable voice to its support. A
British North American, James Kirkpatrick, a physician from South Carolina,
restarted the practice in London in the early 1740s, reporting on its success fol-
lowing an epidemic in Charleston; he claimed that he had developed a safer
method. From that point, variolation gradually spread across other elite circles
and medical establishments in Europe.
By the middle of the century inoculation had become a cause in the
Enlightenment’s campaign against ignorance and superstition. A prominent
French man of science, Charles Marie de la Condamine, became the great pro-
pagandist for inoculation in France, and the philosophes came to his support:
d’Alembert, Voltaire, and that great Enlightenment broadside, Diderot’s
Encyclopedia. Tronchin, contributing an article on “Inoculation” to the
Encyclopedia, praised the technique: “It is therefore incumbent on the faculties
of theology and medicine, the academies, the heads of the magistracy, and men
of letters to banish the scruples fomented by ignorance and to make the people
feel that its own interest, Christian charity, the good of the state, and the conser-
vation of mankind are involved in the establishment of inoculation.”33
Peter Razzell has argued that variolation spread widely enough in the eigh-
teenth century to make an important demographic contribution, at least in Great
Britain, Ireland, and British North America. Razzell claims that inoculation was a
well-established practice of folk medicine in Britain before 1700, and—more
124 The Burdens of Disease

important—that it became very widely used in the years after about 1760, so
much so that it led to a decline in the overall death rate of the British popula-
tion.34 Much of Razzell’s thesis rests on his enthusiastic appreciation of the role
of Robert Sutton and his son Daniel, aggressive promoters of inoculation in the
1760s and thereafter. The Suttons popularized a new method of inoculation,
involving a much shallower incision to engraft the smallpox matter; the result,
according to Razzell, decreased rates of contagion from the inoculated, greatly
reduced mortality rate from inoculations, and progressively attenuated the sever-
ity of the smallpox engrafted without any loss in powers of immunity. By reduc-
ing popular (and perhaps well-deserved) fear of mortality from the procedure,
the Suttons increased the acceptance of inoculation and performed it on many
thousands of people.
At the same time inoculation became considerably less expensive, as belief in
the necessity of “preparation” weakened. Previous to the 1760s, physicians, sur-
geons, and apothecaries had urged that inoculation be preceded by a period of
bleeding, purging, and dietetic treatment, which would bring the body’s humors
(and the purses of the health professionals) into the proper balance to profit from
the inoculation. This preparation considerably increased the costs of the process
and thus limited its spread, unless a practitioner who had less allegiance to
humoral medicine could be found. The Suttons had their doubts about the
humoral theory, and they deserve some credit for lowering costs, but they did
not advocate the complete elimination of “preparation.” According to Razzell, the
chief spur to the reduction of preparation time and costs was the pressure of the
Inoculation came to be widely practiced in British rural areas, partly through
such enthusiasts as Daniel Sutton and Thomas Dimsdale and partly through the
activities of local public relief administration (parishes), whose officials might
come to see the expenses of variolation, provided gratis to the poor, as lower
than those of public burial of victims and public maintenance of widows and
orphans. After 1770, charitable dispensaries funded by philanthropists began
extending inoculation to more of the British urban poor.36 But many city people
remained unenthusiastic about inoculation, perhaps because smallpox in
crowded cities, more truly endemic, inspired in the population a fatalism which
assumed that all small children would get the disease in any case.
Dimsdale acquired particular celebrity when he successfully inoculated
Catherine II of Russia (and some members of the Russian nobility) in 1768.
Catherine subsequently wrote Voltaire that the opponents of inoculation were
“truly blockheads, ignorant or just wicked.” Voltaire exulted: “Oh Madam, what
a lesson Your Majesty is giving us petty Frenchmen, to our ridiculous Sorbonne
and to the argumentative charlatans in our medical schools! You have been inoc-
ulated with less fuss than a nun taking an enema.”37
Disease and the Enlightenment 125

Such incidents lend support to Razzell’s argument about the importance of

inoculation. But some points remain controversial. Even a very widespread prac-
tice of the procedure may not have produced a level of immunity sufficient to
affect mortality rates. Inoculation may have remained dangerous, a vehicle for
diffusing smallpox as well as suppressing it. And did smallpox itself account for
enough deaths so that any reduction in its severity could have made much demo-
graphic difference?38 Thomas McKeown thinks not; although the work of
Carmichael and Silverstein suggests that smallpox was a significant seventeenth-
and eighteenth-century cause of death, what proportion is “significant”? Finally,
the persistence of smallpox as a serious disease into the nineteenth century calls
into question the effectiveness of eighteenth-century preventive measures.
It is tempting to see Edward Jenner (1749–1832) as a characteristic figure in
the eighteenth-century relation between medicine and experimental science,
because (on the surface, at least) Jenner’s development of a smallpox “vaccine”
seems an illustration of a determined empirical procedure followed by a medical
professional who also manifested a generally wide-ranging curiosity about
nature. Just what Jenner did, however, has long been controversial. He certainly
changed the history of smallpox inoculation. Jenner, the son of an English coun-
try clergyman, took up a surgeon’s career, traveling to London to study with John
Hunter, who (with his brother William) was perhaps the leading developer of
surgical techniques and teaching in Europe. After several years in London Jenner
returned to a country surgical practice in western England. Natural curiosity and
experimentation had become, in the eighteenth century, part of the world of
English country gentility; clergymen, physicians, surgeons, attorneys all might
examine nature and publish their observations, in the manner of the classic
Natural History of Selbourne written by the clergyman Gilbert White in 1789.
For Jenner, this milieu’s natural curiosity had been further prodded by his
friend and mentor Hunter, an indefatigable experimentalist whose appetite for
natural knowledge knew no limits: “Have you any caves where Batts go at night?
[Hunter asked Jenner] . . . have you got the bones yet of a large Porpass I wish
you had. . . . I have received my Hedge Hogs. . . . Have you any queer fish? . . .
Send me all the Fossils you find . . . Cannot you get me a large Porpass for either
Love or Money?”39 Over the years Jenner established a successful surgical prac-
tice, both in rural Gloucestershire and in the fashionable spa town of Cheltenham;
while he did so he pursued natural knowledge in the miscellaneously curious way
suggested by Hunter’s requests. Most notably, Jenner made an important contri-
bution to understanding the strange nesting behavior of the cuckoo. He also, over
a long period of time beginning in the 1770s, took note of rural stories about a
coincidence: that victims of “cowpox” did not contract smallpox. He collected
such information slowly and not very single-mindedly, building up some cases of
people known to have suffered from cowpox who later resisted smallpox, either
126 The Burdens of Disease

from contagion or from variolation (which procedure Jenner himself practiced).

In 1796 Jenner inoculated eight-year-old James Phipps, not with smallpox, but
with cowpox; he then subsequently attempted to variolate Phipps with smallpox,
and observed no smallpox symptoms. In 1798 Jenner resumed these tests, inocu-
lating cowpox in a series of children, passing this mild disease from one to
another. When they too resisted subsequent smallpox inoculations, Jenner
described these results in An Inquiry into the Causes and Effects of the Variolae
Vaccinae, and the word “vaccination” entered circulation. Mild, nonscarring cow-
pox apparently conferred an immunity to lethal smallpox.
Some prominent London medical men took up Jenner’s cause. By 1800 physi-
cians in continental Europe were demanding more information and the prepara-
tion of cowpox “vaccine.” Napoleon became Jenner’s admirer, Thomas Jefferson
personally vaccinated his own children, the kingdom of Denmark made vaccina-
tion compulsory as early as 1810, while in 1802 the British Parliament awarded
Jenner the gigantic sum of £10,000, followed by a further £20,000 in 1807.
But controversy enveloped Jenner and his vaccination from the very start,
and what Jenner had actually done remains unclear. Derrick Baxby has convinc-
ingly argued that great difficulty attends any attempt to identify the true compo-
sition of Jenner’s “vaccine.”40 It may have been, as Razzell and other
anti-Jennerians have argued, simply contaminated smallpox variolae.41 The pres-
ent Vaccinae virus, now solely the product of the laboratory, is not identical to
modern cowpox. Baxby offers the tentative suggestion that Jenner’s vaccine and
the modern Vaccinae were both derived, not from cowpox, but from a now-
extinct variety of horsepox.42
Of course no knowledge of viruses existed in 1798, and the controversies that
accompanied Jenner’s “discovery” revolved around other issues. Was Jenner’s
vaccination safer than variolation? Its proponents said yes; opponents said either
that Jenner hadn’t presented enough evidence or that his “cowpox” was in fact
dangerous. Benjamin Moseley claimed that “cowpox” was really syphilis. Did
Jenner show that vaccination was truly effective against smallpox? If so, was its
effect permanent? Jenner rashly argued that one vaccination conferred life-long
immunity to smallpox, and only gradually did his supporters realize that that was
not so. Some other controversy was certainly professional: inoculators resented
the challenge to their methods, their esteem, and their business, while disagree-
ments about priority in the “discovery” also arose.
For all the controversy, however, Jenner soon won acclaim as a hero of the
human race and a symbol of the march of enlightenment against superstition.
Following Denmark’s lead, a number of European states compelled vaccination
for their entire populations, including Russia in 1812 and Sweden in 1816.
Vaccine hospitals and Jennerian societies promoted the practice, while charity
schemes evolved to provide the poor with vaccine. In the first decade of the
Disease and the Enlightenment 127

nineteenth century, eager Europeans had carried vaccines to distant corners of

the earth: India by 1802, China and the Philippines by 1805.
The spread of vaccination was uneven, however. In rural districts, particularly
in the British Isles, empirical practitioners clung to the established variolation
method. The credulous could be convinced that catching an “animal” disease—
cowpox—might in some way reduce one’s humanity, “animalizing” one.
Confidence in vaccination was shaken by the gradual realization that one vacci-
nation was not enough; although Jenner’s opponents had raised that question
from the start, he only reluctantly conceded doubt, and the first systematic revac-
cination began in 1829, in Württemberg.
Despite the triumphs of scientific medicine that inoculation and vaccination
represented, smallpox remained a serious disease in the nineteenth-century
West. As such it illustrated two particularly nineteenth-century problems of dis-
ease and health: the relation between disease and urban poverty, and the mount-
ing questions about the proper regulatory role of the state. Smallpox persisted in
part because vaccination led to an unwise suspension of concern, because
poverty might lead to overcrowding, itinerant vagrancy, and lack of access to
vaccine, and because the liberal state hesitated to compel vaccination (or any-
thing else) on a free people. Autocratic Russia compelled vaccination early, but
lacked the effective bureaucratic apparatus to enforce such a rule; liberal Britain
made no such move until 1853, and liberal France not until 1902, as smallpox
vaccination became an important symbolic issue in the state’s powers over pub-
lic health. The discussion of smallpox will resume in Chapter Twelve.

The history of the West’s confrontation with scurvy parallels its experi-
ence with smallpox in several ways. Scurvy, like smallpox, became an important
disease in the early modern centuries. In the eighteenth century a workable pre-
ventive was “found,” although no one understood why it worked. Scurry became
the subject of considerable experimentation; and in the wake of the scientific
revolution new explanations of its cause appeared that illustrated the general
approaches of the new science.
Scurvy, a disease of nutritional deficiency, arises in populations that consume
inadequate amounts of vitamin C, or ascorbic acid. Although scurvy’s history is
very ancient, it first attracted specific Western attention as a by-product of the great
age of exploration that started in the late fifteenth century. Certainly the isolated
poor, particularly in the villages of northern Europe, had suffered from scurvy in
the winter for many centuries, but the coming of spring annually brought some
vegetables (however few) and thus relief. Prolonged ocean voyages posed more
extreme nutritional problems, and concentrated them in populations that the gov-
erning elites were bound to notice. Magellan’s voyage across the Pacific in 1520–21
128 The Burdens of Disease

included a passage of more than three months out of sight of land, between the
straits that bear Magellan’s name and the Marianas; in the course of that journey,
as in the course of many others, scurvy ravaged the crew with its brutal symptoms:
skin covered with purple spots, limbs weakened, and gums swollen grotesquely
over the teeth in a way that made eating nearly impossible.
As Europeans ventured more frequently on transoceanic voyages (and car-
ried enslaved Africans with them), scurvy became a more frequent companion.
And as the economic and political importance of those voyages grew, so too did
the problem’s perceived severity. Remedies for scurvy were not lacking; if any-
thing, too many remedies existed, all with adherents. The benefits of oranges
had been noticed as early as Vasco da Gama’s voyage to India around the Cape
of Good Hope in 1498, but that was only one in a forest of solutions, and only in
the eighteenth century did careful empiricism establish the relative merits of the
preventives.43 That sea voyages suffered from scurvy in the meantime is beyond
doubt. The British naval expedition of 1740 commanded by George Anson may
serve as a good example. Ordered to venture into the Pacific and attack Spanish
possessions and shipping, Anson set sail with six warships and over 1,900 men.
From the standpoint of military victories and booty the voyage succeeded
immensely, including as it did the capture of a westward-bound (that is, silver-
laden) Manila galleon. But when Anson’s sole remaining ship returned to Britain
in 1744, 1,400 of his original force had perished, about 1,000 of them from scurvy,
as against only 4 from enemy action.44
Such depredations stimulated theories about the cause of the disease.
Humoral medicine believed scurvy a disease of the spleen and thus associated it
with an excess of black bile. Humoral therapy therefore urged removal of black
bile by purging and attention to diet. Seventeenth-century thinkers in both the
chemical and the mechanical camps disagreed, and their beliefs led to compet-
ing therapeutic schemes. Mechanical philosophy placed emphasis first on the
thinness (or thickness) of the blood, and by the eighteenth century had come to
see the atmosphere as playing an important role in scurvy (as well as in many
other diseases) . The elasticity of the air, it was believed, related to perspiration
and thus to the proper (with a nod in the direction of Harvey) “circulation” of
body fluids; cold and wet air, of the sort found on shipboard (and especially below
decks) interfered with perspiration and brought on scurvy. Therefore, some
eighteenth-century thinkers urged, proper ventilation would prevent scurvy.
Chemical philosophers held to another view. Seventeenth-century iatro-
chemists such as van Helmont saw scurvy as the product of either excess acid or
excess alkali (depending on the symptoms), and so they proposed a chemical
readjustment of (to use a modern term) the body’s pH, perhaps through diet,
perhaps through chemical remedies. This chemical interpretation took a
new form in the eighteenth century, with the interest in pneumatic chemistry
Disease and the Enlightenment 129

stimulated by the discovery of the different constituents of the previously ele-

mental “air.” Joseph Black isolated one of the first of the gases, carbon dioxide,
in the 1750s. For a time, through the 1770s, Black’s “fixed air” was a sovereign
remedy for scurvy, until—by the 1780s—it was realized that the body produced
“fixed air” all the time anyway. But in the meantime “fixed air” had also been
related to a therapy that had been popular through much of the century: the use
of malt as both preventive and cure. Carbon dioxide was succeeded as a wonder
drug by another exciting product of pneumatic chemistry, oxygen. That gas’s
name meant “acid former,” for late eighteenth-century thinkers believed that it
was a component of all acids. Therefore oxygen was part of chemical remedies
for scurvy caused by excess alkali.
All these theories, and trial-and-error practices as well, resulted in a wide vari-
ety of answers. Spurred by the disasters of Anson’s voyage, the British naval sur-
geon James Lind conducted a sophisticated experiment (the results of which
were published in 1747), in which he tried a number of different scurvy reme-
dies under well-controlled conditions. One of the remedies, the use of oranges
and lemons in the diet, gave the most favorable results. But this experiment, so
decisive to our minds, made little impression on Lind, let alone on others.45 Lind
and his contemporaries believed that scurvy must have layers of cause, with
some factors “predisposing” victims to the disease; one simple dietetic remedy
could not by itself be sufficient. In the 1740s Lind held to the atmospheric the-
ory, and supported the numerous trials of ventilating ships; when by the 1760s
those trials gave poor results, Lind became uncertain and discouraged. His 1747
essay had not convinced its readers of the powers of citrus fruits; it had not even
convinced its author; but it did leave the field open for continuing trial and error
and experimentation.
That empiricism was followed, in a much less controlled way, by the celebrated
Pacific explorer James Cook, whose voyages between 1768 and 1779 are often
mistakenly said to have shown the way to the use of citrus against scurvy. Cook
carried with him a vast battery of different supposed antiscorbutics—his own
favorites being malt and sauerkraut—and supplied his seamen with all of them.
His voyages were remarkably free of scurvy, but what he had shown was not at all
clear to his contemporaries. As O.H.K. Spate says, “so many nostrums were tried,
without controls, that it was like killing a bird with a shotgun; impossible to say
which particular pellet was fatal.”46 In the year after Cook’s death in Hawaii in
1779, the British fleet in the English Channel suffered 2,400 cases of scurvy in ten
weeks, proving that Cook had not established the unique power of citrus fruit.
The successful arguments on behalf of citrus turned out to be empirical, not
theoretical. Gilbert Blane, a British physician with both naval experience and
social connections, approached the subject in a Baconian, collect-all-the-facts
way, and in the 1780s and 1790s gradually persuaded British naval and political
130 The Burdens of Disease

leaders of the virtues of citrus fruits as a prevention and cure of scurvy. In 1795
the British Admiralty bowed to the weight of Blane’s persuasions and ordered a
daily ration of citrus juice for its crews. But understanding of the cause of scurvy,
or of the reasons for the efficacy of citrus, lay in the future.

How Complete Was Enlightenment?

Even in the eighteenth century, the era of science and enlightenment,
when human reason exulted in the powers conferred on it by the giants of the
scientific revolution, continuities rather than change dominated much of the
West’s relations with disease. Physicians’ therapies, even for those who could
receive the finest medical care, remained fundamentally Galenic, as the well-
documented and -discussed case of the “madness” of George III of Great Britain
illustrates.47 And epidemic outbreaks made the case for continuity even more
clearly. One such epidemic, at the end of the century, brought a prosperous and
self-consciously enlightened Western city to its knees.
In 1793 yellow fever fell on Philadelphia, then the capital of the United States,
one of the largest (outside London) English-speaking cities in the world, and cer-
tainly one of the most “enlightened,” the city of Benjamin Franklin. This epidemic
began in August, and by September and early October the city had been badly crip-
pled. Although numbers are not precise, it seems likely that 5,000 Philadelphians
died in those months, of a total population of about 55,000, while as many as 20,000
others fled the city. Benjamin Rush, a leading Philadelphia physician of the time,
estimated that as many as 6,000 residents were ill from the fever at a single time.
Yellow fever is an acute viral disease, which reaches humans through the
bites of the mosquito species Aedes aegypti. Yellow fever is highly virulent; dras-
tic symptoms of suffering—a sudden onset of high fever, skin hemorrhages,
pains, vomiting, and then internal hemorrhages—are often succeeded by death.
The mortality rate of yellow fever varies widely, but in some epidemics may
approach 50 percent. In the eighteenth century Western civilization began
encountering this basically tropical disease more frequently, as European
contacts with the tropics multiplied. (A more thorough discussion of European-
tropical disease connections is found in Chapter Nine.) For European medical
opinion, slowly working its way through arguments about the nature of “fevers,”
this terrifying disease took its place in that broad category. Philadelphia debates
over yellow fever’s cause and nature illustrated many of the general themes of
such eighteenth-century discussions. Was yellow fever a single unique disease?
Or was it located on a continuum of fevers and so a variant (however extreme) of
a general type? Was it of essentially foreign origin, carried to Philadelphia by
contagion from the tropics? The recent arrival of refugees from French Haiti lent
credence to that belief. Or, as many eighteenth-century thinkers believed, did
yellow fever arise from a miasmic atmosphere?
Disease and the Enlightenment 131

These questions roiled the Philadelphia medical community, one dominated

by physicians who had received the best education that the English-speaking
world afforded. Many of them had studied in Edinburgh or London, and were
imbued with the traditions of William Cullen, the Monros, and the Hunters. The
city itself had a university, where a medical college had been founded in 1765,
the first such institution in British America. The city also had a medical society
and the American Philosophical Society, founded under Franklin’s inspiration in
1743. Philadelphia’s civic pride, which the doctors shared, did not mean unanim-
ity of opinion when the epidemic struck. Some physicians, led by Rush, insisted
that the sources of filth in the city produced a lethal miasma; a particular target
for this opinion was a rotting heap of spoiled coffee, dumped on a wharf by a ship
from the Caribbean. Not all physicians agreed with Rush. William Currie led a
party which insisted that the fever had been borne by contagion from foreign
Within the general frameworks of “miasma” and “contagion,” other more spe-
cific theories of cause flourished: for instance, electric fluids in the air were
“invariably fatal” and the large number of lightning rods in Franklin’s city, “by
imperceptibly drawing off the electric fluid from the clouds,” put Philadelphia in
peril.48 Beside these up-to-date scientific speculations, many older beliefs coex-
isted. The yellow fever was a divine visitation punishing the wicked, perhaps a
specific judgment on the sins and errors of the new nation, perhaps a judgment
on that urban life abominated by supporters of a commonwealth of free farmers.
Echoing very old theories about plague, some believed that fear itself might
cause the fever. Especially if contagion was blamed, scapegoats might suffer,
with the French refugees from Haiti the obvious targets.
Different theories of cause, as always, called forth different responses to the
emergency. Many urged prayer. For many—perhaps 20,000—either miasma or
contagion prompted flight from the noxious air of the city or from the bearers of
the disease. The Philadelphia experience did add a twist to the old arguments
about the presumed effects of a quarantine on a city’s commerce. For several
centuries European city governments had struggled to control contagious dis-
ease in the face of the objections of merchants who saw quarantines as unaccept-
able interference with trade. In Philadelphia in 1793, however, the merchant
community saw the doctrine of miasma as the greater threat, for it might say to
the world that fever was “native” to Philadelphia, tainting all the city’s products
and inhabitants. The state government was thus moved to act—cautiously—on
the contagion theory, and it imposed a quarantine on incoming goods and
people. Of course other American towns and cities reciprocated, declaring quar-
antines on movements from the beleaguered capital. Mail from Philadelphia was
dipped in vinegar before being opened.49 But because the contagion theory did
not have universal support, a variety of schemes were suggested to clear the
132 The Burdens of Disease

miasma. No really systematic cleanup was undertaken, however; the offensive

pile of coffee apparently stayed on the wharf for some time, perhaps because
those who most feared its effects were therefore most leery to approach it and
clean it up. Some citizens fired guns in the streets in the belief that doing so
would purify the air.
Many of the city’s services collapsed, as those who performed them sickened,
died, or fled. The federal government simply closed down; President George
Washington retired to his Virginia estate. Much of state government likewise
came to a halt. The city administration was kept alive, though barely, by the
determined mayor Matthew Clarkson, an ad hoc committee of citizens, and the
efforts of Philadelphia’s African-American population, who (like the poor in gen-
eral) could least afford flight. Their actions included the commandeering of prop-
erty for an isolation hospital and an orphanage, staffing those institutions, raising
money for supplies, organizing the burial of the dead, conveying the sick, caring
for the destitute, and burning or burying the property of the deceased. The
ad hoc committee acted in a clear and long tradition of urban response to
epidemics; Renaissance Italian cities had created such committees, before their
evolutions into standing boards of health.
Doctors attacked the disease with a wide range of remedies, none of them
clearly effective, although recoveries enabled them to claim success. Many of
the therapies, regardless of their theoretical connections with modern science,
varied little from old humoral traditions. Benjamin Rush, in the midst of the epi-
demic, became messianically committed to a savage regimen of bleeding and
purging, including massive doses of calomel (a favorite mercury-based purge)
and venesection that removed up to a quart of blood several times in as many
days. His zeal, his prior standing, and his political reputation carried many along
with this astonishing therapy, but some doctors disagreed and urged a gentler
approach, notably Jean Devèze, a Frenchman who assumed medical charge of
the city’s isolation hospital. Between the careful Devèze and the heroic Rush
could be found a wide range of herbal remedies, purges, decoctions, and sug-
gestions for healthy diets and habits, purveyed by physicians, apothecaries, and
a group of empirics whose connection with “official” medicine was even more
blurred in North America than it was in Europe (although less so in Philadelphia
than in the backwoods).
Political issues affected theories of cause and remedies alike. Rush enjoyed a
prominent political as well as medical position. He had been an ardent republi-
can and had signed the Declaration of Independence. When Alexander Hamilton,
the Federalist secretary of the treasury, was struck by yellow fever in September
1793 his rapid cure, in the care of one of Rush’s medical opponents, acquired
political overtones; was “Federalist” medicine superior to that offered by Rush,
Disease and the Enlightenment 133

the friend of Thomas Jefferson and James Madison? Rush himself believed that
Hamilton might have accepted his therapies if only their politics had coincided.
The epidemic may have had political effects as well. It broke out in the middle
of the most determined attempts by revolutionary France to enlist the alliance of
the United States. Some years later John Adams claimed that the epidemic had
prevented a revolution led by Citizen Genêt, the French envoy, the goal of which
would have been to force Washington to join France’s war with Britain or be
overthrown. And while modern historians concur with Dumas Malone’s view
that Adams “exaggerate[d] both the political dangers of the times and the effects
of the plague on them,” the epidemic certainly resulted in a period of political
paralysis as the government dispersed and neither political rallies nor news could
come from Philadelphia.50 Washington and those who supported his neutralist
stance more easily maintained an inactive position.
The epidemic also exacerbated internal divisions. Controversy about the merits
of Rush’s “heroic” therapy intermingled with broader arguments about the nature
of American culture. Rush believed that civic virtue and a successful volunteer effort
at governance (in conjunction with his therapeutic measures) had saved the day,
but others, seeing failure where Rush saw triumph, drew different conclusions. Eve
Kornfeld believes that the epidemic weakened Philadelphia’s cultural primacy in
the new nation; its united and confident cultural community broke apart, and Rush
formed a new and rival academy of medicine among his supporters.51
The Philadelphia yellow fever epidemic serves as a useful summary of the
eighteenth century’s disease history. The episode displayed the characteristics
of the Enlightenment: its environmentalism, its search for causes in such physi-
cal phenomena as the atmosphere and electricity, its eclectic and divided noso-
logical arguments, and its self-consciously “scientific” approach. Much, however,
remained from earlier times: appeals to providence, visions of doom, searches
for scapegoats, and the overt associations of therapies and political positions.
While rationales for therapies had changed, remedies in the humoral tradition
persisted in practice. The orthodox practitioners of medicine offered no clear
therapeutic advantage over the empirics. If medicine made any contribution to
the reduction of eighteenth-century death rates, it did not do so in its response to
violent epidemics.
The roles of disease, and the attempts of Western thinkers and actors to con-
trol it, remain unclear for the period of the eighteenth century. It is possible that
eighteenth-century hospitals, at least in some places in Europe, were not the pos-
itive menaces to health that French revolutionaries, determined to make a dra-
matic case for reform, made them out to be. It is difficult to agree with
E. M. Sigsworth that reformed hospitals may have positively contributed to
health, however.52 Although a significant reform in nursing practices was under
134 The Burdens of Disease

way in some parts of Germany (see Chapter Ten), it had not spread widely.
Physicians and other healers clearly had no stronger grip on the causes of
disease at the end of the century than they had at its beginning. Epidemics still
baffled everyone. Any possible demographic impact on the death rate from
human “medical” action must rest on two bases: the preventive measures that
evolved against smallpox, scurvy, and malaria; and the indirect (and still largely
uncomprehended) effects on environment, particularly those that interfered with
disease vectors such as insects. The jury remains out on the general demo-
graphic impact of both those ameliorations.

Cholera and Sanitation

C holera occupies a somewhat anomalous position in the history of dis-

eases that have affected Western civilization. It shares many of the characteris-
tics of plague: its suddenness of onset, its horrible symptoms, its high rate of
mortality, and its apparent inexorability. For many nineteenth-century people
cholera seemed as much a visitation from a vengeful God as plague had seemed
to Europeans in 1348. And as they had in 1348 Europeans took flight when they
could; as in 1348, they searched for the sinful who had brought on the disease
and made scapegoats of them. Social turmoil followed in cholera’s wake. But
cholera also appeared at a time when science was making more extensive claims
of explanation, and when many societies were groping toward the control of dis-
ease through social and political action. Cholera’s victims might be as helpless
as plague’s had been, but nineteenth-century thinkers were hardly resigned to
that fact.
Cholera’s position in historical writing has also been anomalous. For some it
qualifies as the great disease drama of the nineteenth century, one that more-
over focused attention on the environmental evils of early industrial urbaniza-
tion. But much recent scholarship has discounted the importance of cholera in
either the evolution of etiological theory or the development of sanitary prac-
tice, and we have recognized that its demographic impact was slight. It is as
though cholera represented the last gasp of an earlier period of disease his-
tory. Nineteenth-century thinkers recognized its horrors, but were more con-
cerned with an agenda determined by endemic complaints such as tuberculosis
and “fevers,” an agenda in which this violent Asian visitor did not find a clear

136 The Burdens of Disease

Cholera in 1831
The shock value of the disease came in part from its newness on the
Western scene. Cholera had been at home on the Indian subcontinent for cen-
turies. In warm river waters the causative microorganism (Cholera vibrio) flour-
ished, reaching humans most often through water, but also carried on infected
food or from hand to mouth. Microorganisms passed through digestive tracts
and reentered water supplies through excreta. The growth of commerce and
communication between India and Europe increased the likelihood of its impor-
tation from its Bengal home, and the imposition of British authority on the sub-
continent increased the human (and disease) interchanges among regions of
India itself. A major cholera epidemic began in India in 1817; from India the dis-
ease spread to Afghanistan and Persia and thence into Russia, appearing at
Orenburg in 1829. From Orenburg it traveled into the West with remarkable
rapidity, considering that the age of steam travel had scarcely begun. Cholera
reached the major cities of Russia in 1830, spread to the Baltic in 1831, and by
that autumn jumped into England. Northern Europe felt the disease in 1832, as
did North America; cholera reached southern Europe, as well as Central and
South America, in 1833. As railroads and steamships appeared in subsequent
years, later episodes of cholera moved with even greater speed, with especially
severe epidemics in 1848–49, 1853–54, the middle 1860s, and the early 1870s.
One of the most serious outbreaks occurred as late as 1911, in Naples.
Europeans took fright at cholera’s virulence, and with reason. Mortality rates
from cholera approached those of plague, for roughly half of its victims died. It is
worth noticing, however, that cholera’s morbidity rate fell far below that found in
the great plague epidemics, and even below that customarily maintained by
nineteenth-century tuberculosis. Cholera affected about 35,000 people in Paris in
1832 (in a population of 785,000), for example, and about 17,000 people in
Hamburg in 1892 (in a population of 620,000).1 Cholera is not particularly easy to
catch. Although the microorganisms must have been plentiful during the
nineteenth-century epidemics, many people probably ingested them without
harm, for human stomach acids often kill the organisms before they reach the
intestines where the trouble starts.
That trouble could devastate the victim. Cholera came as a sudden, over-
whelming attack, most notably of dehydration marked by vomiting and profuse,
uncontrollable excretion. The drastic loss of body fluids collapsed the tissues;
coagulated blood ceased to flow, the skin turned alarmingly blue, and the heart
(or the kidneys) failed, often within a few hours. People perfectly healthy in the
morning died by nightfall, having undergone some hours of great agony. And
the bourgeois of the nineteenth century found such a death particularly repug-
nant, for his sensibilities about the grosser body processes were becoming more
acute. Cholera could strike down a prim middle-class man away from the privacy
Cholera and Sanitation 137

of his home, leaving him collapsed in his own excrement on the street or in a
railroad car. A more shameful condition was hard to imagine.
The inexplicability of cholera’s attack increased its impact on the imagination
of the time. Cholera appeared in Europe and America when confidence in the
powers of science had been receiving enthusiastic expression for over a century.
Although (as Chapters Five and Six have suggested) the new science did not
always consistently affect the practice of Western medicine, nineteenth-century
European medicine took pride in its status as a “science.” It could point to one
clear triumph: the reduction of the peril of smallpox through cowpox vaccina-
tions; it had self consciously allied itself with the experimental method; it trum-
peted its reliance on observation and eschewed the old Galenic categories as
explanations of disease. New and exciting etiologies and nosologies filled the air.
Cholera, an alien embodiment of an oriental “other,” rebuked that pride. Modern
medicine had many different explanations of cholera, but those explanations con-
flicted. More important, modern medicine offered neither a convincing cure nor
good advice on how to avoid it. The physician’s therapeutic arsenal relied on a
melange of bleedings and purgings that candid members of the learned profes-
sion admitted had little effect.
In the 1830s opinions about the causes of cholera reflected more general etio-
logical arguments that had a long history and that were (as the previous chapter
has shown) very far from settlement. By the early nineteenth century the conflict
between “contagion” and “miasma” was beginning to favor the latter. Progressive
opinion, according to Erwin Ackerknecht, saw atmospheric pollution as a domi-
nant cause of disease, partly for political reasons. The contagion doctrines that
had gained ground in the late Middle Ages in the wake of bubonic plague
epidemics had led (as we saw in Chapter Three) to the creation of health
boards, cordons sanitaires, and systems of quarantine, what their eighteenth-
century advocate Johann Peter Frank called “medical police.” To the generations
of the American and French Revolutions such state machinery represented unrea-
sonable limitations on the freedom of the individual. Quarantines, as we have seen,
certainly disrupted trade and inspired widespread resentment. To some
Enlightenment thinkers medical police and the theory of contagion that lay behind
them symbolized all that was wrong with the Old Regime: its corruption, its
tyranny, its superstition. Further, the liberal-bourgeois background of many physi-
cians predisposed them to this politically motivated anticontagionism.2
But politics did not provide the sole argument. A more general environmen-
talism dominated much of the thought of the Enlightenment. And an apparent
lack of evidence also troubled the contagionist theory. “Contagion” meant a
direct passage of the disease from one person to another. When the mechanism—
the physical mode of transmission—could not be shown, contagionism
remained an unproved hypothesis. The discovery of microscopic “animalcules,”
138 The Burdens of Disease

van Leeuwenhoek’s “wee beasties,” in the seventeenth century promised at first

to show such a mode of transmission; but as the eighteenth century went on the
beasties resisted indictment for any specific disease. If the beasties couldn’t
be shown to carry a disease, then how (apart from vital or chemical action at a
distance) did it pass from a sufferer to a new victim?
Contagion clearly explained one disease: smallpox. Fluids from a smallpox
patient, injected in a healthy person, resulted in a new case. The venereal char-
acter of syphilis suggested another mode of contagion. But attempts at inocula-
tion against other diseases in the hope of proving their contagious nature
discouraged the contagionists, for in a large number of experiments only a few
cases “took.” Still weightier arguments derived from experience with some seri-
ous epidemic diseases. Europeans experienced yellow fever primarily in the
West Indies, but their encounters with the disease elsewhere suggested its sea-
sonal character; why should a contagious disease cease transmission when the
weather changed? In the 1793 yellow fever epidemic in Philadelphia the parti-
sans of miasma were strong, and the Barcelona epidemic in 1821 was even more
decisive. On the latter occasion the French physician Nicolas Chervin, who had
practiced in America and was acquainted with Benjamin Rush, maintained that a
“miasma” produced yellow fever. Travelers from Cuba did not bring the disease,
as the contagionists argued. It arose from bad air produced by open sewers and
other filth. By 1827 the French government agreed and lifted its quarantine laws
that applied to yellow fever. Plague, largely absent from western Europe (though
not from eastern Europe) since the early eighteenth century, also seemed sea-
sonal in character; plague also affected poorer districts more severely (as would
cholera), which suggested the significance of local environmental conditions.
As cholera spread it posed problems for both contagionists and proponents of
miasma. If cholera was contagious, why did it suddenly appear in a section of
town out of touch with cholera victims? Why did it not affect medical personnel
who attempted to care for the sufferers? If a miasma was responsible, why did
the disease strike some people in a town and not others? Why did the disease
seem to move along routes of human traffic?
When cholera first made its way into Russia the czar’s government, acting on
vaguely contagionist advice, imposed quarantines and ordered the isolation of
victims. The czar, after all, possessed a strong state regulatory apparatus (at least
in theory), and political liberalism was no threat to contagionist measures in
Nicholas I’s Russia. But the Russian state measures failed to halt the advance of
cholera, and serious consequences resulted. Elsewhere in Europe the Russian
experience discredited contagionist measures such as quarantines and enforced
isolation, although they may have failed because the Russian application of them
was neither consistent nor complete; the czar’s police system was stronger on
paper than in practice. And not only did the Russian measures fail to halt the
Cholera and Sanitation 139

spread of cholera; they led to major social turmoil, when the heavy police pres-
ence necessary to enforce isolation led to serious riots in St. Petersburg.3 Would
governments act on the theory of contagion when doing so might be not only
ineffective but positively dangerous politically? In a Europe brimming with revo-
lution in 1830–1832, why look for trouble?
Although thinkers in Western countries reacted in a number of ways and with
a number of beliefs, a rough consensus emerged in the early 1830s that in a way
overrode the “contagion” versus “miasma” debate. Why did cholera strike its
victims in such a whimsical way? Nineteenth-century minds rejected blind
chance. Cholera’s descent on a victim, whether it moved through person-to-
person contagion or through some environmental cause, was apparently contin-
gent on some other factor that predisposed certain people to the disease. And
while such thinking about “predisposing causes” went back to the medieval
plague, it assumed new force in a time when the contagion-versus-miasma debate
seemed inadequate. Peter Baldwin has suggested that the debate was overtaken,
in different ways in different places, by a general acceptance of a contingent
On what was cholera “contingent”? For some the answer remained the
Almighty. Fearing a scourge of the entire society, the British government called
a national day of fasting and humiliation, although it did so only after a fanatic
member of Parliament embarrassed his colleagues with his prophecies of
national desolation. President Andrew Jackson vetoed a similar proposal in the
United States, holding that such a resolution violated the constitutional separa-
tion of church and state. But attempts to see in cholera a general divine punish-
ment were weakened by the particular incidence of cholera. In 1348—when half
the population was affected—a general curse seemed more plausible than it did
in 1832. Did God single out individuals, or at most social groups? And if so, on
what basis? In America, for example, were African Americans or recent immi-
grants the targets of His wrath?5
More common were associations of cholera with individual immorality or irre-
ligion. The Wesleyan Methodist Magazine reported: “On the Christmas day, two
men (one of whom was a notorious dog fighter) were fighting in a public house,
in a state of intoxication, near the Wesleyan chapel, and that too during the time
of worship there. One of them died of the cholera in a few hours after, and the
other in two days!”6 And the question of immorality of course opened a Pandora’s
box of possibilities, for immorality too often lay in the eyes of the beholder. Did
immorality mean drunkenness? Licentiousness? Failure to observe the Sabbath?
Blasphemy? Or might “immorality” include such characteristics as laziness,
imprudence, or stupidity?
With the last-named traits we move (perhaps insensibly) from the realm of
moral conceptions of disease toward theories of social causation. English village
140 The Burdens of Disease

churches that observed the day of fasting and national humiliation collected
money to relieve the suffering of the poor. Henry Hunt, the British radical,
pointed out that one-third of the population fasted almost every day of the week.7
When cholera invaded France in 1832, studies of its incidence showed meaning-
ful statistical correlations between poverty and the disease. René Villermé
(1782–1863), a pioneer medical statistician, used the evidence from cholera to
bolster his arguments that poverty, not environmental “miasma,” was the true
cause of disease. But what caused poverty? For the laissez-faire thinkers of the
Manchester School, individual failure produced poverty, and the solution to
poverty therefore lay in individual achievement: work hard, abandon dissolute
habits of drinking and womanizing, save and do not spend. Villermé himself,
who pointed out the human problems of the industrial system and thus criticized
much Manchester thinking, could offer little more in the way of solution. Public
health and the avoidance of disease, he said, were clearly social problems at
heart, not environmental ones, but his remedy was the education of the poor into
better habits.8 To some observers in America, the habits of the poor violated
God’s natural laws, and so virtue—and health—might be gained by education in
those natural laws.
Before the completion of Villermé’s important studies—almost before cholera
even appeared—Europeans and Americans had associated cholera with social
class and economic background. Whether one held a doctrine of “contagion” or
“miasma” made little difference: slums propagated cholera, whether because
they polluted the atmosphere or brought their dwellers into proximity with oth-
ers. In Britain, France, and the United States the governing and middle classes
feared cholera as a threat to social stability, for it might provoke the anger of the
lower orders, it might spread to others, and measures against it might disrupt
the economy. Such fears added weight and perhaps bile to the faltering and
uncertain measures of public health undertaken in 1831 and 1832: cleansing of
streets and districts, isolation of victims, quarantines. The St. Petersburg experi-
ence was repeated, as in many places such measures sparked countering fears
in the poorer classes. Cleansing and isolation interfered with traditional patterns
of life, and the poor feared attacks on those traditional ways. Those fears related
to many issues. The poor feared doctors as representatives of another class and
as purveyors of remedies often nauseous or painful, and so they resented legally
mandated confinement in isolation hospitals in the hands of doctors.
In Britain the fear of doctors in 1831 gained a particular edge from the recent
and horrible revelations of the case of Burke and Hare, Edinburgh criminals who
murdered the homeless poor and sold their bodies to anatomical lecturers who
paid and asked no questions. Small wonder that an Edinburgh crowd “pelted the
medical men with mud and stones, shouting ‘medical murderer,’ ‘cholera hum-
bug’ and ‘Burkers’ ” at surgeons who tried to treat a cholera victim, or that a crowd
Cholera and Sanitation 141

in Manchester cried, “To the hospital, pull it to the ground” on their way to attack
it.9 In Britain and France alike the poor could hear Malthusian voices who seemed
to urge the purging of excess population. The drastic symptoms of cholera
brought “poison” to the popular mind; were the governing classes engaged in a
dreadful plot to reduce the numbers of the poor? Variations on that theme
appeared elsewhere. In Russia, for example, the St. Petersburg rioters might
blame the foreign physicians who dominated the medical community there, or
perhaps the Poles, then rebelling against Russian rule; in Russian Poland, cholera
could be seen as a poison spread by the Russians.10 National and/or class resent-
ments boiled over in St. Petersburg, Moscow, Warsaw, Paris, Edinburgh,
Glasgow, and Manchester. Hospitals, doctors, government functionaries, the
police all found themselves under attack. And—for the governing classes—such
disorders proved the ignorance and superstition of the lower orders.
Meanwhile physicians grappled with other possible “contingent” causes. In
places as far apart as New York and Hamburg, doctors emphasized the impor-
tance of maintaining morale, in the belief that a despondent state of mind predis-
posed one to cholera. Many doctors shared—or gave voice to—the more general
beliefs that the disease stemmed from sin, poverty, dirt, or some combination of
them; but nowhere did a precise consensus emerge, and a wild garden of thera-
pies flowered. Calomel, for example, frequently prescribed as a powerful purga-
tive, was both a common choice and (we would now think) a catastrophic
treatment for dehydration, one that led Norman Howard-Jones (in 1972) to call
nineteenth-century cholera therapy a “form of benevolent homicide.”11
But despite the lack of consensus, the experience of cholera did contribute to
some shifts in medical thinking, most notably in conceptions of discrete disease
entities and their relationships to human physiology. As we saw in Chapter Six,
some medical thinking by the early nineteenth century maintained that diseases
were local in character, not systemic as ancient Galenism had held. Despite these
new ideas, a pathology that emphasized disorders of the humors, or fluids mov-
ing through the whole system, had deep roots in Western thought. Associated
with such a pathology was a conception of diseases along a continuum, in which
(for example) one suffered from a greater or lesser imbalance of black bile.
According to this view one might have a little cholera, or a lot of it. But if disease
was a specific malady, associated with a particular “poison” or external agent and
affecting a particular organ of the body, then either you had cholera or you did
not. In the nineteenth century, eclectic and uncertain nosological ideas gradually
moved toward the specific, discrete conception of diseases. French thought, in
the revolutionary period, had especially leaned in that direction. Broussais—not
surprisingly—saw cholera as an inflammation of the gastric tract, brought on by
ingestion of a specific poison found in the environment. To Broussais (and to
other French physicians, many of whom did not otherwise agree with him) the
142 The Burdens of Disease

significance of cholera lay in its specificity, and not in whether it was or was not
contagious. But in some other places cholera did not play an important role in
medical thought; thus British medical opinion gave more attention to the contin-
uing problem of “fevers” than to the episodic cholera.12

The Gospel of Sanitation

For some, cholera’s Asian origins meant a concern with “Asian” envi-
ronments, particularly with the poverty, crowding, and dirt of India. But the envi-
ronmental problems might not be imports. The great cholera epidemics and the
explosive growth of industrial cities in the Western world certainly coincided. In
the early nineteenth century British cities offered the most dramatic examples of
that growth, but by the 1880s others had joined them (see Table 7.1).
More important than raw numbers, however, were the circumstances of much
urban growth. Housing construction proceeded with great speed and with
accompanying great carelessness: flimsy buildings, ill-ventilated and ill-heated,

Table 7.1
City Populations: 1800, 1850, 1880

1800/1801 1850/1851 1880/1881

Great Britain
Birmingham 71,000 223,000 401,000
Edinburgh 83,000 194,000 295,000
Glasgow 77,000 345,000 587,000
Leeds 53,000 172,000 309,000
Liverpool 82,000 376,000 553,000
London 1,088,000 2,491,000 3,881,000
Manchester 75,000 303,000 341,000
Continental Europe
Berlin 172,000 419,000 1,122,000
Budapest 54,000 178,000 371,000
Lyons 110,000 177,000 376,000
Moscow 250,000 365,000 612,000
Munich 40,000 110,000 230,000
Paris 547,000 1,053,000 2,269,000
St. Petersburg 220,000 485,000 877,000
Turin 78,000 135,000 254,000
Vienna 247,000 444,000 726,000
United States
New York 63,000 696,000 1,912,000
Philadelphia 81,000 388,000 847,000

Sources: C. M. Cipolla, ed., The Fontana Economic History of Europe, vol. 4, The Emergence of
Industrial Societies (London: Collins, 1973), 750; B. R. Mitchell, Abstract of British Historical Statistics
(Cambridge: Cambridge University Press, 1962), 24–27.
Cholera and Sanitation 143

provided very overcrowded living space. In some cities, such as Liverpool, over-
crowding often involved quarters below street level, where water constantly
seeped in.
Arrangements (or lack thereof) for the disposal of excrement bedeviled these
cities, and the large number of large animals in the cities exacerbated that prob-
lem. Most human wastes found their way either into leaky cesspools or directly
into street drains. Water-flushed toilets, an invention of the eighteenth century,
were still rare, a decided mark of status, and in any case simply conveyed the
wastes out of the house into the same cesspools or street drains. Cesspools
leaked into the surrounding soil; when they were cleaned (perhaps only yearly)
their contents wound up in rivers or were sold to “night-soil” contractors to be
stored in a dump that oozed into the water table. Sewers, where they existed,
were constructed on the ancient model: large tunnels into which streets drained,
large enough to accommodate the men who cleaned them and hence large
enough to allow the formation of great stagnant pools. City water supplies came
from a variety of sources, including private contractors; most often the contrac-
tors used either local ground water (in which sewage might mix) or local rivers.
Most urban rivers were simply appalling, and as the century went on they got
worse. Trash, sewage, animal (and human) bodies befouled them, as did a grow-
ing mixture of industrial pollutants.
What Hans Zinsser said of early modern warfare—that it provided ideal con-
ditions for a gigantic natural experiment in epidemiology—might with equal jus-
tice be said of nineteenth-century cities and their environments.13 Waterborne
diseases such as typhoid fever and dysentery (and of course cholera) ran riot.
Overcrowding, poor ventilation, and general dirt favored typhus and tuberculo-
sis; air pollution caused nausea, and hence poor digestion and inadequate nutri-
tion, as well as discouraging clean clothes and the provision of ventilation.
A growing panoply of industrially related diseases added other health problems:
asthmas suffered by miners, cutlers, and potters; necrosis (“fossy jaw”) associ-
ated with match manufacture; bleach workers exposed to chlorine; rubber work-
ers exposed to naphtha; and the widespread industrial use of poisonous lead and
In addition to the conviction that the “environment” might be responsible for
disease, nineteenth-century thinkers inherited from the Enlightenment a predis-
position to use quantifiable evidence. The great sanitarians of the 1830s and
1840s—René Villermé, Lemuel Shattuck, and Edwin Chadwick—shared a belief
in statistics. All believed in the power of civilization to eradicate disease. Each
received a stimulus, or at least evidence, from the early cholera epidemics. As we
have seen, Villermé used the 1832 Paris experience to show correlations between
mortality and poverty; he was convinced that (as William Coleman puts it)
death was a social disease. Since for Villermé the root cause was poverty, not the
144 The Burdens of Disease

environment, he perhaps should not be called a sanitarian at all. His remedies

did include some environmental action against urban congestion, for he urged a
return to small-scale manufacturing and the settlement of workers on small plots
of arable land. More important, his arguments became crucial to the French
thinkers called (by Coleman) le parti d’hygiène, a diverse group of intellectuals
and empirical investigators who flourished in the years after 1825. Criticizing
Rousseau’s view that civilization had led to degeneration, they assiduously col-
lected facts about hygienic conditions in the conviction that civilization created
the power to solve hygienic and public health problems.15
Lemuel Shattuck (1793–1859), a Boston publisher and genealogical scholar,
became interested in community statistics. In 1841 he published an analysis of
the vital statistics of Boston that demonstrated the declining health of the town.
For this Shattuck found a moral cause; disease, he believed, was “a penalty for
deviation from moral behavior,” and could be avoided by a regimen of “Godliness
and cleanliness.”16 But the return of the cholera in the late 1840s helped to con-
vince him that, although disease remained fundamentally a moral problem, the
state must intervene to protect public health. A Massachusetts legislative com-
mission that he chaired (1849–50) blamed the environment for deteriorating
health, saw social factors as responsible for environmental change, and urged
state responsibility for eliminating social and environmental evils by regulating
or eliminating wastes and undertaking central water and sewer systems.
Although Massachusetts did not act on this report for two decades, Shattuck had
planted the sanitationist flag in the United States.
Of all the sanitarians Edwin Chadwick stands foremost, perhaps because his
voice came from Britain, the pioneer industrial society. Chadwick (1800–1890), a
disciple of the philosopher Jeremy Bentham, initially approached the problems
of disease from the standpoint of political philosophy in the service of state
bureaucracy. In 1834 the British Parliament mandated a sweeping change in the
government’s provision of poor relief, and Chadwick took an important position
in the bureaucracy responsible for the new relief system. In Chadwick were bal-
anced the conflicting strands of Bentham’s philosophy. At times that philosophy
endorsed the idea that a society’s greatest happiness could be attained by assum-
ing that each individual could best judge his own interests (and thus that govern-
ment was best which governed least). But at other points individuals’ judgments
had to be educated or in some way directed by the society as a whole (and thus
an enormous regulatory camel might nose into the laissez-faire state’s tent).
The poor-relief reformers of 1834, working on the first of these assumptions,
hoped to make the receipt of public relief unpalatable to the recipient, thus get-
ting the state out of the welfare business and aiding a free labor market; individ-
uals should be left to seek their own best interest with their employers, without
the intervention of an artificial state welfare system. Chadwick agreed, and as a
Cholera and Sanitation 145

Table 7.2
Average Ages of Death in City and Country, England, 1842

Social class Manchester (city) Rutland (countryside)

Professional persons; gentry 38 52

Tradesmen; farmers 20 41
Mechanics; laborers 17 38

Source: G. M. Young and W. D. Handcock, eds., English Historical Documents. 1833–1874

(New York: Oxford University Press, 1956), 779. This work contains a convenient collection of
Chadwick’s 1842 Report: 772–793.

bureaucrat sought to reduce state welfare costs. When a local government

authority illegally spent funds to improve sanitation, Chadwick wondered if such
action might in the long run reduce costs by preventing epidemic disasters. In
the name of lowering state expenses, Chadwick launched an inquiry, at the right
hand of which were two extreme “miasmist” physicians, James Kay-Shuttleworth
and Thomas Southwood Smith. This inquiry resulted in the Report on the
Sanitary Condition of the Labouring Population (1842), the single greatest classic
of the sanitation movement and one that outsold well-known novels.17
Whereas Villermé had argued a causal connection between disease and
poverty, Chadwick’s Report found the major correlation to be between disease
and dirt. The best-known illustrations of the Report contrasted the health of rural
areas with the sickness of the great industrial towns (see Table 7.2). In a famous
sentence Chadwick proclaimed “that the annual loss of life from filth and bad
ventilation is greater than the loss from death or wounds in any wars in which
the country has been engaged in modern times.”18 Chadwick was impressed by
the differences between bucolic Rutland and teeming Manchester; Villermé
would have looked at the same table and noticed the differences between gentry
and laborers. Villermé’s perspective raised awkward questions about the justice
and wisdom of capitalist society, and Villermé shied from some possible answers.
Chadwick’s view threatened no such embarrassment. No fundamental restruc-
turing of the class system would be needed; society simply had to clean itself up.
G. M. Young said of Chadwick: “Born in 1800, in a Lancashire farmhouse where
the children were washed all over, every day, the mainspring of Chadwick’s
career seems to have been a desire to wash the people of England all over, every
day, by administrative order.”19
For Chadwick the key to a clean society lay in the provision of integrated
water-and-sewer systems for towns. The prevention of disease therefore became
the responsibility of engineers, not of physicians (whose abilities Chadwick
distrusted), and certainly not of socialist revolutionaries (whose hand Villermé
146 The Burdens of Disease

unwillingly reinforced). Chadwick insisted on a “fully articulated” water-and-

sewer service, embodying a steady supply of piped fresh water to each dwelling,
house drainage, street drainage, and main sewers connected to each dwelling.
The hydraulic force of the water supply constantly pushed wastes and sewage
along. Flush toilets were crucial, and so too were sewer pipes of a narrow diame-
ter, laid in steep gradients, through which the flushing water could forcefully
propel wastes. The sewage should be carried out of the town, and there
(Chadwick believed, following the ideas of the German chemist Justus Liebig)
turned into fertilizer.
How to build such a fully articulated service? The money, expertise, and
power that would be needed to override vested interests could come only from
government. Such a system would require a massive construction project in
every city, at great cost. It would strain the rights of private property, for what
good would be a sewer system if property owners were not compelled to join it?
It would confront overlapping and even competing local authorities, especially in
Britain; in Birmingham three different sets of commissioners existed for
drainage and four for surveying, all intensely jealous of one another. The
Benthamite Chadwick therefore—in the name of public health—advocated a sin-
gle local authority, acting under guidelines set by the central government’s
expertise. Chadwick, though an arch-anticontagionist, was hardly an antistate
liberal in the conventional Manchester sense.
Chadwick’s Report was an impassioned piece of propaganda, which appealed
both to a desire for political stability and to fears of such horrors as cholera.
Water and sewer engineering works could be seen as tools of social control, and
while they eventually involved huge capital outlays, they also represented what
Christopher Hamlin has called “arguably the greatest ‘technical fix’ in history,”
one that avoided the larger questions of poverty.20 In 1848, the British Parliament
approved a Public Health Act that re-created the Central Board of Health that
had fallen into desuetude after the waning of the 1832 scare; more than that, the
1848 act empowered local boards of health to enforce drainage, build sewers,
compel the servicing of cesspools, pave and clean streets, deal with nuisances,
inspect lodging houses and burial grounds, control the water supply, and raise
local taxes to pay for it all. Chadwick’s vision had passed into legislation. Some
cities showed earlier interest in such Chadwickian activity than others, but in the
second half of the century cities both in Britain and elsewhere gradually took up
the sanitation cause. The sewer and water systems of Paris and London ranked
with the greatest engineering projects of a century that elevated engineers into a
cultural pantheon. In London, sewer construction began after yet another cholera
outbreak in 1853–54 provided a spur; main sewer lines there were completed in
the 1860s, but the entire system took decades. The municipalization of water
supplies similarly stretched over the years.
Cholera and Sanitation 147

Chadwick’s emphasis on water-and-sewer systems stemmed from a convic-

tion in the miasmatic origin of disease, a doctrine couched in general terms for
much of the eighteenth and early nineteenth centuries, concerned with the envi-
ronment in toto, with particular attention to the “atmosphere” as the cause of
trouble. The filth of streets and in rivers was feared because such conditions
affected the surrounding air. Attacks on filth undertaken by health boards aimed
at the improvement of atmospheric quality; water or ordure might be targets not
in their own right but as contributors to a totality of environmental pollution.
Thus the British authorities argued in 1849 that polluted streams gave rise to
atmospheric corruption. In the course of the 1850s, however, some thinkers
became convinced that water in and by itself might be the carrier of disease. In
1854 John Snow, a London physician, carried out what may be seen in retrospect
as a classic epidemiological investigation. He studied two adjoining districts of
London, very similar in their social and economic compositions, one of which
suffered a far higher incidence of cholera than the other. The districts were
served by different water supplies. Cholera, Snow argued, was therefore a water-
borne disease.
Although Snow made some converts to his view in subsequent years, many
observers still fit his findings into the framework of a more general environmen-
talism. The different water supplies affected the immediate atmospheres of the
two adjoining areas differently. The miasma theory, that is, could argue that even
closely adjacent neighborhoods might not share the same airs and vapors. But
Snow’s arguments became part of a slowly developing focus on water itself. In
the 1850s the condition of the Thames, London’s river, became an important
political issue for reasons that had more to do with national image than with a
view of water as the specific bearer of disease. British politicians, arguing that
the filth of the Thames reflected poorly on pride of an imperial people, deter-
mined on an at least semicollectivist body of regulation to clean up the river.21
Chadwick’s advocacy of a complete water and sewer system should be seen
in that perspective: a general environmentalism, in which some greater empha-
sis was being accorded to water, for a mixture of aesthetic and practical reasons.
In subsequent years Chadwick’s campaigns made headway partly because of
that confluence of general environmental beliefs with concern about water.
Another cholera visitation in 1866 stimulated more argument. Snow and his
allies, notably William Farr and Edward Frankland, pressed their view that pol-
luted water produced cholera. But questions remained unanswered, particularly
about the actual mechanism of pollution carried by the river. Where was the
cholera “poison” to be found? If the water carried a poison, why did it not affect
everyone who drank it?
One of the first European cities to build an “articulated service” was Hamburg,
and that city’s experience introduces us to the evolution of thought about cholera
148 The Burdens of Disease

in the years when general miasma gradually gave way to emphasis on water.
After a disastrous fire swept through Hamburg in 1842 a British engineer named
William Lindley, a Chadwick disciple, carried the gospel of sanitation and anti-
contagionism to the city fathers. Prodded by Lindley, the German port con-
structed a water-and-sewer system according to Chadwick’s principles.22
Hamburg became a shining beacon to the sanitationists. Yet in subsequent
decades European perceptions of disease in general and cholera in particular
underwent changes as evidence appeared for contagion mechanisms. Hamburg
suffered a catastrophic cholera epidemic in 1892, and that disaster illustrated
both the uncertain state of etiological theory and the continuing importance of
political factors in responses to diseases.
By the 1850s sanitationism dominated approaches to public health. Three dif-
ferent champions had come forward to build on Chadwick: John Simon, Florence
Nightingale, and Max von Pettenkofer. To Chadwick, disease arose from a cor-
ruption of the air, in turn generated by the exhalations of filthy waters, sewers,
ground, and organic matter; thus disease should be attacked by the systematic
cleansing of the (especially urban) environment. Relatively little emphasis fell on
personal hygiene, and Chadwick’s anticontagionist views discouraged such state
measures as quarantine and isolation of individuals. John Simon (1816–1904), an
able surgeon and pathologist, was most responsible for carrying out Chadwick’s
program in Britain, initially as the first “Medical Officer of Health” for London
(in 1848) and then as chief medical advisor (with several different bureaucratic
titles) to the central government between 1855 and 1876. Although his etiologi-
cal views gradually shifted away from Chadwick’s dogmatic anticontagionism,
Simon took the lead in chevying the complex world of British local government
along, propagandizing the cause of sanitation, offering central government loans
to local governments for sanitation projects, and sending expert central govern-
ment inspectors into the provinces. For Simon, as for Chadwick, what was at
stake was not state action, but what sort of state action; neither was a laissez-faire
liberal, although anticontagionism was central to their beliefs.23
Florence Nightingale (1820–1910) achieved a legendary position in world
public opinion in the 1850s as a result of her activities in the Crimean War
(1854–1856), when she reorganized the military nursing services. From that time
forward she was revered, especially in the English-speaking world, as the Lady
with the Lamp. If secular nineteenth-century society had saints, she headed the
list. Nightingale’s role in the professionalization of nursing will be discussed
in Chapter Ten. Here I note her role as an important sanitary reformer. Shortly
after her return from the Crimea, Nightingale fell ill, and believing herself
at death’s door, she lived as an invalid for fifty-three years. Possessed by a
sense of urgency, she commissioned, cajoled, and commanded studies of public
health conditions, studies undertaken by her followers and coordinated by her.
Cholera and Sanitation 149

If anything her belief in the miasmatic origin of disease exceeded Chadwick’s, as

she applied her energy and intelligence to sanitizing first British army quarters
and then the Indian subcontinent.
Max von Pettenkofer (1818–1901), a Munich medical scientist, hygienist, and
nutritionist, introduced a complex and sophisticated explanation of cholera’s
cause in the 1850s and 1860s. Cholera, he concluded, shared both contagious
and miasmatic aspects. A contagious (“x”) factor might come from human exc-
reta, but particular soils and ground waters (factor “y”) had to act on that conta-
gious matter before cholera resulted, and for Pettenkofer the soils and ground
water were the crucial elements. Pettenkofer became the most influential sani-
tarian of his generation, especially in Germany. Rather like Villermé and unlike
the English sanitarians, he placed more emphasis on personal hygiene and less
on the intervention of the state’s regulatory apparatus. He urged individual effort
and education, in the best nineteenth-century liberal tradition.
Whether sanitarians demanded bureaucratic expertise (as did Chadwick)
or looked to individual efforts to expunge filth (Pettenkofer) or poverty
(Villermé), one message dominated: a clean society would be a healthy society.
“Cleanliness is next to Godliness,” a sentiment ascribed to both Francis Bacon
and John Wesley, became a nineteenth-century cliché, especially for the middle
classes of Western society. Personal and community cleanliness became a sym-
bol of civilization, and their absence represented barbarism. Of course, as
Richard Evans has pointed out, the middle and upper classes possessed certain
advantages: it was far easier to stay clean in larger houses with servants and
perhaps fewer children than in small, crowded, servantless quarters.24 The
gospel of cleanliness might therefore be seen as part of a self-justifying class
ethic, but its strength in mid-nineteenth-century opinion about disease was
nonetheless real.
Sanitationism in the 1860s was clearly allied with science. It had elevated a
new class of technical experts to a position of authority: statisticians, meteorolo-
gists, engineers, and chemists such as Liebig (enticed to a professorial chair in
Munich by Pettenkofer). Even if the understanding of disease was not yet clearly
in the hands of physicians, it had apparently been taken from the hands of
theologians once and for all. As Charles Rosenberg has noticed, American
thinkers in 1832 saw cholera as either a punishment from God or a consequence
of the neglect of God’s natural laws. By the epidemic of 1866 God had nearly
disappeared from American thinking about cause, and the New York Board
of Health—created in response to that cholera visitation—had sweeping
Chadwickian powers to clean the city.25 Perhaps because the Civil War had
accustomed Americans to heavy state intervention, public authority assumed
more power. Did that happen in part because the miasma doctrine wound up
placing more responsibility for disease on society as a whole? If disease was a
150 The Burdens of Disease

product of individual moral failure, then society bore no responsibility. Villermé’s

conclusion—that poverty was the problem— placed a great potential burden of
responsibility on society, but he shrank from its implications and urged individ-
ual efforts to escape poverty. A doctrine of dirt and miasma could place blame on
dirty individuals or groups, thus preserving the liberal ideal of individual initia-
tive and responsibility; but it opened the door to social action as well, for an entire
community might be affected by the irresponsibility of those who fouled the
ground and water that all must use.

Cholera and “Germs”

By the 1860s another scientific view of the cause of cholera (and of dis-
ease in general) had reappeared: the “germ” theory. We should not assume that
this theory was self-evidently true in those years, and it did not assume a position
of dominance for some decades. Could a tiny microorganism produce such dras-
tic effects as the symptoms of cholera? It seemed improbable, and that difficulty
of relating huge effect to trivial cause was only one of a number of arguments
raised against the theory (see Chapter Ten). But if microorganisms did cause
disease, then an explanation of contagion might be at hand. The germs simply
traveled from one person to another. Could the transmission be shown? In 1876
Robert Koch traced the life history of the organism responsible for anthrax, a
disease of cattle and sheep; Koch cultivated the organism in his laboratory and
with it transmitted anthrax to previously healthy animals. By 1882 Koch had iso-
lated and traced his first human disease microorganism, that of tuberculosis,
and in 1884 he announced that the causative agent of cholera had been found.
Yet still the argument left miasmists unconvinced.
The case of Hamburg illustrates the difficulties facing the germ theory.26
Hamburg’s city government retained considerable local autonomy within the
federated German Empire, a legacy of its long history as a free city. All through
the nineteenth century Hamburg’s government was among the most liberal in
Germany, as a merchant oligarchy held political sway. Contagion theories found
little support in Hamburg; health boards, with their quarantines and isolations
that interfered with trade, had only advisory powers there. Hamburg did not
require smallpox vaccinations until after a serious smallpox epidemic in 1871,
long after compulsory vaccinations had been adopted in many other states,
including liberal Great Britain. Hamburg spokesmen consistently downplayed
the menace of cholera. The ideas of Pettenkofer, with their emphasis on individ-
ual responsibility and personal hygiene, found particular favor there.
When Koch and his followers announced the discovery of the cholera
microorganism in 1884 the germ theory gained many followers, especially in
Germany, where national pride in Koch’s achievements might have been a
factor. Koch was a strong proponent of state action: quarantine, state-directed
Cholera and Sanitation 151

disinfection, careful policing of the water supply, isolation hospitals. Richard

Evans argues that Koch’s ideas fit into a growing tendency for state intervention
in the society and the economy, especially in Germany in the 1880s, the decade
of rising tariffs, campaigns against socialism, and the beginnings of the German
Empire’s welfare-state legislation. An active state public health machinery might
also give the imperial government a justification for overriding the local powers
of governments such as Hamburg’s.
By the same token Koch’s ideas constituted a political threat to state govern-
ments, and Hamburg feared the centralizing power of Berlin, dominated as it
was by statist Prussians. In the 1880s and early 1890s doubts still existed about
the role of Koch’s germs in causing cholera, and Hamburg’s elite seized on those
doubts. Koch—and before him his teacher Jacob Henle—had laid down what
became the ruling postulates of bacteriology. The “Koch postulates” said: (1) that
the organism should occur in every case of the disease, (2) that the organism
should occur fortuitously in no other disease, and (3) that after being isolated
from the ill person and grown in laboratory cultures, the organism could induce
disease in another subject. For obvious reasons Koch and his followers had not
applied the third postulate to their cholera organism. Another weakness existed
as well. One of the great triumphs of the germ theory was its application to pre-
vention by means of “vaccination,” or the development of attenuated doses of
causative bacteria that would, when administered, confer on their recipients
immunity from the full-blown disease. Such vaccines had been produced by
Louis Pasteur for a number of animal diseases, but Koch’s attempts at an effec-
tive vaccine for his first human disease germ, tuberculosis, repeatedly failed.
Was the germ theory flawed? Hamburg’s political and medical establishment
had some reason to distrust Koch’s cholera solutions.
Hamburg, as we have seen, possessed a proud water-and-sewer system.
Unfortunately its water did not pass through a sand-filtration process, so that if
sewage, carrying a deadly bacterial load, washed upstream to the source of the
water supply, the town could be infected. That happened in 1892. Those circum-
stances weakened the apparently straightforward case for John Snow’s view of
cholera as a waterborne infection, and gave Pettenkofer’s picture of disease
appearing after water fermented the soil some credibility. The mere provision of
an “articulated service” provided no guarantees, especially if the sewers emptied
into the same river from which the water supply was drawn.
But what was to be done? Koch was certain: kill the microorganisms in the
water and stop their transmission from those already suffering from the disease.
Hamburg officials were not persuaded, since stopping transmission meant quar-
antine, isolation, and disinfection. When cholera broke out in Hamburg in August
1892, almost certainly brought to the city by emigrants in transit from the Russian
Empire to North America, a fatal period of hesitation ensued; the city fathers,
152 The Burdens of Disease

fearing an adverse effect on commerce, hesitated to pronounce an epidemic, and

the bacteriological tests that Koch advocated to confirm the presence of the dis-
ease proved difficult to perform. Koch, with the pressure of the imperial govern-
ment in Berlin behind him, eventually arrived on the scene and compelled the
adoption of his remedies as the epidemic worsened. The 1892 epidemic provided
a convincing demonstration of the germ theory, for areas of Germany that fol-
lowed strict quarantine and isolation procedures escaped Hamburg’s fate. Those
areas included the adjacent city of Altona, in Prussian territory.
On the heels of the Hamburg epidemic the German Reichstag debated a com-
prehensive Epidemics Bill that would confer on the imperial government the
powers that Koch had assumed, de facto, in Hamburg. The debates on the bill
occasioned continuing argument between Koch’s supporters and the miasmists,
led by the now-venerable Pettenkofer. When his arguments were rejected by a
committee discussing the bill, Pettenkofer performed the most radical medical
experiment of the nineteenth century: he obtained a culture of cholera bacilli
from Koch’s laboratory and swallowed it. Severe diarrhea resulted, but
Pettenkofer survived; one of his assistants then repeated the experiment before
a large group of witnesses, with the same result. The germ itself, said
Pettenkofer, could not cause the fatal cholera; other factors—soil, water—must
interact with it. But these bizarre experiments did not contain a swelling conta-
gionist, germ theory tide; by the end of the century medical opinion was over-
whelmingly contagionist, miasmists were on the professional margins, and the
germ theory had had many triumphs.
Paradoxically the German Epidemics Bill did not pass until 1900; the
Reichstag lost interest when the shock of the Hamburg cholera epidemic wore
off, and the bill only passed in response to fear of bubonic plague, which had
revived in Asia in the 1890s. The plague organism had been identified by Yersin
and Kitasato in 1894, and although its path of infection was not positively traced
for some years, in 1898 Simond suggested the involvement of rats and fleas in a
chain of contagion. Cleansing and disinfection might therefore interrupt this ter-
rible scourge. With that spur the bill passed and the German government
assumed new powers. Medical officers could compel quarantines that sealed
borders, order disinfection of private property, and forcibly isolate individuals in
hospitals. The simple provision of a water-and-sewer system—the contribution
of the engineers—no longer seemed adequate. The bacteriologist, the new
expert, must analyze the water the engineer provided and the sewage he washed
away, as the state undertook to monitor waters and wastes.
The German Epidemics Law of 1900 may serve as the terminus of the convo-
luted tale of cholera and the sanitation movement. A cholera scare contributed
to the bill’s formulation, but not to its final passage. Its provisions, and the
Cholera and Sanitation 153

arguments that surrounded it, encapsulated the overlapping etiological theories

of the nineteenth century, for while contagionism lay behind the powers it con-
ferred on the state, those powers recognized that contagion passed through the
environment and not just through immediate person-to-person contact. When
the Epidemics Law passed, furthermore, the waterborne infections that attracted
epidemiological attention were rapidly ceasing to carry their former menace.
The campaigns for pure water and safe sewage disposal had their effect; in many
cities by the 1870s, 1880s, and 1890s, typhoid fever, dysentery, and cholera were
becoming rare. The belated enlistment of bacteriology perfected the engineers’
campaign, but the germ theory played a complementary role, not a primary one.
Cholera provided dramatic episodes of disease in the nineteenth century. The
shock of cholera, and indeed of other diseases, at times added urgency to the
demands of the sanitationists, but many other factors aided them as well: city
fathers’ reluctance to spend money on improvements might be overridden by
civic pride, the gospel of cleanliness acquired an evangelical zeal that had little to
do with disease or etiological theories, and the power and prestige of scientific
professionals and experts increased over the century, regardless of the theory
they advocated. The prestige of engineers and chemists aided anticontagionism
in mid-century; by the end of the century the lab-coated bacteriologist symbol-
ized science.
The triumphs of sanitation (and germ theory) may conceal from us the fail-
ures of the nineteenth century. The causes of infant mortality had hardly been
addressed at all, and it remained very high in 1900. Although some nineteenth-
century thinkers had associated disease with poverty, a culture of poverty still
existed in almost all countries in the West. Urban overcrowding, inadequate
nutrition and hygiene, and a general lack of community preventive care all meant
that influenza and a variety of “fevers” still ran rampant. Tuberculosis waned in
some areas (for reasons to be discussed in the next chapter), but the major med-
ical attacks on its causes lay in the future. Compulsory school attendance, becom-
ing more common, created new opportunities for such diseases as polio and
diphtheria. Attempts to compel notification of illness to authorities had only
begun: in Great Britain in 1889, in Germany in 1900, for example. Governments
remained loath to admit the presence of some diseases in their territories. In
1911 the Italian government launched a remarkable (and remarkably success-
ful) campaign to deny that the cholera epidemic ravaging Naples existed at all.27
Air pollution and the pollution of waterways were virtually untouched. Although
some were beginning to recognize industrially related diseases, the regulation of
hazardous materials in manufacturing processes remained very spotty.
But while an imposing list of failures certainly existed, the nineteenth century
also marked the age when Western thinkers became convinced that any scourge,
154 The Burdens of Disease

even one as terrible as cholera, could be met and defeated. That important con-
viction would inspire assaults on a broad spectrum of diseases in the twentieth
century. As long as those assaults proceeded under the banner of “science,” they
might win general assent. Questions of poverty and social attitudes loomed over
the remedies for other diseases, however. Tuberculosis, the true plague of the
nineteenth century, slackened not when—or because—a causative microorgan-
ism was found, but as a result of changes in social conditions and beliefs.

Tuberculosis and Poverty

I n the nineteenth century more people in the Western world died of

tuberculosis than of any other epidemic disease. The “White Plague” generated
enormous fears, for good reason. Yet for all its importance, and all the attention
lavished on it, tuberculosis presented a tangled picture to nineteenth-century
thinkers, who could not agree on its causes. Of great antiquity, tuberculosis
appeared in different symptomatic guises, inspiring a great variety of etiological
theories and an even greater variety of therapies, while different social and polit-
ical beliefs became associated with those theories and treatments.
Twentieth-century microbiologists gained a firmer grip on the causes of tuber-
culosis, which (we now believe) has a number of manifestations and may be
caused by two different organisms: Mycobacterium tuberculosis or Mycobacterium
bovis. The first of these (although it may infect other animals as well as humans)
passes from person to person, most often via the respiratory system. The second
infects most domestic animals and reaches humans when they consume the
products of such diseased creatures. The bacteria lodge in many possible places
in the human frame. Mycobacterium bovis often finds its way into glands and
joints, and one group of symptoms that results is called scrofula, the medieval
“King’s Evil” (see Chapter Two). Although Mycobacterium tuberculosis may also
infect different parts of the body, when it settles into the lungs it may produce
pulmonary tuberculosis, known earlier as “consumption” or “phthisis.” Many
people infected with M. tuberculosis do not develop “consumption” at all, how-
ever, and many others only show consumptive symptoms after a long period of
infection. A large number of others do develop such symptoms, and it was that
pulmonary form of the disease—“consumption” or “phthisis”—which attracted
particular nineteenth-century attention. But for all that apparent simplicity and

156 The Burdens of Disease

certainty, the history of tuberculosis remains unusually complex even in the con-
text of past epidemics. The rhythm of its past severity has not yet been convinc-
ingly explained, so that even with a surer grasp of its “cause,” we cannot be
certain why it savaged the early nineteenth century and abated in the late nine-
teenth and early twentieth.

Early History
Tuberculosis in humans has an ancient history, revealed by pale-
opathology. The Hippocratic writings of the ancient Greeks discuss consump-
tion at length. Some evidence—scanty to be sure—suggests that its ancient and
medieval incidence varied more or less directly with population density. Thus
classical Roman civilization, relatively urban, may have suffered high rates of
tuberculosis, while the medieval West, rural and thinly settled especially in its
early centuries, offered fewer opportunities for contagious respiratory infections.
The resurgence of tuberculosis in the West, accompanying the urban growth of
the twelfth and thirteenth centuries, may have affected the incidence of that other
great mycobacterial killer, leprosy (see Chapter Two). Certainly by the early
modern period of European history tuberculosis had resumed a place among the
major epidemics, and in that period (coinciding with the scientific revolution) a
diverse collection of explanations of phthisis arose.
Those explanations rested, first of all, on an understanding of the sensible
symptoms of the disease: shortness of breath, coughing, blood-flecked phlegm,
progressive weakness and debility, and loss of skin color, all of which only
became characteristic of the disease in its later stages. The persistence of such
complaints in the same family encouraged notions about the hereditary charac-
ter of consumption, notions that had found expression as early as Hippocrates
and that the chronic nature of the disease perhaps strengthened. The prolonged
presence of a victim of a chronic disease may burn images into the memories of
onlookers, and these may be recalled when others in the same family recapitu-
late the symptoms. But not all early modern theorists accepted the hereditarian
explanation. Others, attracted to the general notion of contagion that gained
credence in the sixteenth and seventeenth centuries (see Chapter Three),
applied that to consumption as well as to plague. The consumptive, like the
leprous the victim of a chronic complaint, posed a long-standing threat by her
simple existence; that sense of danger, perhaps intuitively felt by neighbors,
was given theoretical justification by the doctrine of contagion. Both these
hypotheses—heredity and contagion—remained popular into and through the
nineteenth century and affected responses to the tubercular.
With the improvement of anatomical knowledge between 1500 and 1700 came
an awareness of consumption’s pathological signs, especially the lesions or
“tubercles” formed in the lungs. That knowledge led to other etiological ideas,
Tuberculosis and Poverty 157

especially those that saw such lesions as the product of some form of irritation,
perhaps caused by physical agents such as improper food or ingested matter,
perhaps the product of muscular (or even nervous) exhaustion. Such beliefs
led in turn to therapeutic suggestions: change diet, change environment, rest,
avoid stress. Whether tubercular lesions represented one disease or a panoply of
them formed part of the larger pattern of nosological uncertainty discussed in
Chapter Six.

Tuberculosis and Romanticism

These general etiological views—heredity, contagion, and irritation of
tissue whether physical or psychological—informed Western responses to tuber-
culosis in the age of “romanticism,” when the disease seemed to threaten
the well-born and the gifted. Between the late eighteenth century and the mid-
nineteenth, a variety of cultural circumstances led literate observers to associate
pulmonary tuberculosis with the upper and middle reaches of society, and the
disease acquired an air of fashion. In reality, of course, most of its victims
belonged to the lower orders, but its associations with misery and poverty only
became more widely acknowledged later in the nineteenth century.
Romanticism remains an elusive historical construct, but I will assume here
that it may represent a net of cultural practices and beliefs that had particular
importance between the late eighteenth and mid-nineteenth centuries. Those
practices and beliefs included an emphasis on emotions, mystery, and spontane-
ity as opposed to the Enlightenment’s practice of reason, an interest in the
remote (whether in time or space), and a glorification of the beauties of nature;
politically, “romantics” could be either radically revolutionary (glorying in bold
breaks with tradition and in the virtues of the common man) or very conserva-
tive (viewing aspects of especially the medieval past with favor). Such tenden-
cies, perhaps “endemic” (in Lilian Furst’s words) at all times in some thinkers
and artists, became “epidemic” for many between roughly 1775 and 1850.1 Some
of those tendencies (certainly not all) related to the themes of health, disease,
and death. Romantics, H. G. Schenk argues, suffered a “malady of soul,”
a Weltschmerz, as a consequence of religious frustration; for them the “bonds of
allegiance and belief” to and in religion had been weakened by rationalism, leav-
ing a nihilistic preoccupation with the “dark side of life,” a fascination with sleep,
death, “utter extinction.” Schenk holds that this weariness of life was deepened—
though not primarily caused—by the physical suffering and early death that
came to many of the leaders of romanticism.2
Tubercular experience may also have reinforced a more specific “romantic”
view of disease and its causes. As Hermione de Almeida puts it, “rivalling theo-
ries of disease and its treatment could and did flourish [see Chapter Six], and
the Romantic fascination with the ‘energizing’ ambiguity of illness found ample
158 The Burdens of Disease

domain.”3 Romantic thinkers, de Almeida argues, believed disease to be always

present, part of a continuum of energy that included life itself. An inexorable
chronic condition such as consumption confirmed such a belief, especially for a
poet as well informed as John Keats, who had studied medicine, observed con-
sumption in his family, and then suffered (and died) from it himself.
Certainly a remarkable collection of cultural figures, many of them “roman-
tics,” succumbed in relative youth between 1775 and 1850 (see Table 8.1). Little
wonder that death was a favorite romantic theme, especially the death of the
young, or that romantic writers and artists focused on tombs, sorrowful weeping
willows, and the heart-wrenching ruins of decayed monasteries. Autumn, as René
and Jean Dubos noted in their classic study of tuberculosis, came to rival spring
as the poet’s favorite season: the autumn of melancholy and falling leaves, not
autumn the season of jolly harvest.4
Some of the lives of those in that formidable list (Table 8.1) became paradigms
of romantic tubercular suffering: Novalis, Keats, Chopin, and the Brontë sisters.
Consumption’s victims slowly and chronically declined, gradually wasting away,
becoming fragile and pale. Seeking relief they traveled to warmer climes or
undertook sea voyages. Such travels often took them to the Mediterranean,
where notions of the contagiousness of disease in general and tuberculosis in
particular remained more influential than they did in northern Europe. The tuber-
cular travelers thus met hostility that added to the pathos of their stories: Keats,
feared by his Italian landlady; Nicolò Paganini (1782–1840), the violin virtuoso,
thrown out of a house in Naples; Chopin shunned on Majorca; François René de
Chateaubriand, the French author, unable to sell his carriage in Rome because
he had allowed a consumptive to ride in it. Consumptive northern European
artists who stayed home may have thus contravened medical advice, but their
compatriots, apparently less terrified of contagious disease, may have spared
them such ostracism. The composer Carl Maria von Weber, in the last stages of
consumption, was lionized by concertgoers in London and literally embraced by
his musical admirers, one of whom lent a shoulder to help Weber to his carriage.5
Such experiences contributed to a romantic view of the effects of tuberculo-
sis. A wasted pallor acquired a fashionable beauty; whitening powders replaced
rouge; the Pre-Raphaelite artists of England, in the mid-nineteenth century, exag-
gerated the thinness and paleness of their female subjects.6 Keats saw love and
consumption as closely related products of similar causes; his “La belle dame
sans merci,” de Almeida maintains, serves as an “emblem of the destructive
aspect of love, of frustrated creative endeavor, and of death by consumption,” at
one and the same time.7 Romantic, pathetic literary sufferers abounded: David
Copperfield’s Dora, Dombey and Son’s Little Paul, La Dame aux Camélias’s
Marguerite Gauthier, Scènes de la Vie de Bohème’s Mimi. The last two entered
the operatic repertoire in Verdi’s La Traviata and Puccini’s La Bohème. Perhaps
Tuberculosis and Poverty 159

Table 8.1
Deaths at an Early Age, 1776–1849

*Ludwig Christoph Hölty, German poet 1748–1776

*Johannes Ewald, Danish poet 1744–1781
Wolfgang Mozart, Austrian composer 1756–1791
*Joseph Michael Kraus, German-Swedish composer 1756–1792
*Karl Philipp Moritz, German author 1757–1793
*Novalis (Friedrich von Hardenberg), German poet 1772–1801
*Philipp Otto Runge, German painter 1777–1810
*Cecilia Tychsen, bride of Ernst Schulze 1794–1812
*Ernst Schulze, German poet 1789–1817
*Karl Solger, German philosopher 1780–1819
*Friedrich Gotlob Wetzel, German author 1779–1819
*John Keats, English poet 1796–1821
*Percy Bysshe Shelley, English poet 1792–1822
Erik Johan Stagnelius, Swedish poet 1793–1823
J.L.A.T. Géricault, French painter 1791–1824
George Gordon, Lord Byron, English poet 1788–1824
*Franz Horny, German painter 1797–1824
*Carl Maria von Weber, German composer 1786–1826
Franz Schubert, Austrian composer 1797–1828
*Wilhelm Waiblinger, German poet 1804–1830
*Victor Meyer, German sculptor 1807–1831
*“Napoleon II” (“King of Rome”), son of Napoleon I 1811–1832
Vincenzo Bellini, Italian composer 1801–1835
Karel Mácha, Czech poet 1810–1836
Mariano Jose de Larra, Spanish author 1809–1837
Aleksander Pushkin, Russian poet 1799–1837
Giacomo Leopardi, Italian poet 1798–1837
Mikhail Lermontov, Russian author 1814–1841
*Nicholaus Becker, German poet 1809–1845
*Alphonsine Plessis, French actress 1824–1847
Felix Mendelssohn, German composer 1809–1847
*Emily Brontë, English author 1818–1848
Edgar Allan Poe, American author 1809–1849
*Anne Brontë, English author 1820–1849
* Frédéric Chopin, Polish composer 1809–1849
*Sándor Pëtofi, Hungarian poet 1823–1849

Source: The major source for this table is Erich Ebstein, Tuberkulose als Sckicksal
(Stuttgart: Ferdinand Enke Verlag, 1932).
*Suffered from tuberculosis

the memory of Paganini, playing as one possessed while in the throes of con-
sumption, lent credence to the sopranos who filled an opera house with their
voices despite their characters’ tubercular lungs.
Tuberculosis conferred therefore a kind of beauty; men, according to René
and Jean Dubos, strove for a fashionable emaciated look, a fashion to which even
160 The Burdens of Disease

the corpulent Alexandre Dumas père aspired.8 In addition, some in the early
nineteenth-century also associated consumption with genius. Sensitive souls
seemed prone to consumption. Did consumption impart a nervous force to the
mind? Did it lead to a frantic urge to accomplish something great before the
shadow fell? The empirical evidence for such causal connections was not very
convincing, however, and here as in other respects tuberculosis defied nine-
teenth-century attempts to generalize about its causes or effects. As the Duboses
point out, four of the six children of Thomas and Frances Trollope died of tuber-
culosis between the ages of twelve and twenty-three, showing no sign of literary
gifts. The two other children—Thomas (1810–1892) and Anthony (1815–1882)—
were prolific authors, as was their mother. The Trollope authors never mani-
fested consumptive symptoms.9

The Decline of the Nineteenth-Century Epidemic

Romantic views of tuberculosis may obscure the real demographic
importance of the disease, the greatest epidemic killer in the nineteenth-century
West, and one that affected far more of the poor than the romantically creative.
In the first half of the nineteenth century mortality rates from tuberculosis prob-
ably ranged between 300 and 500 per 100,000 population in most Western coun-
tries. When England and Wales had about eighteen million people (in 1851),
over 50,000 people died there of tuberculosis annually, compared with the 40,000
cholera victims in the worst single cholera year, 1849. Cholera epidemics
appeared as spikes on a graph, but those spikes rarely (if ever) rose above the
high annual level of tuberculosis deaths.
In the second half of the nineteenth century the mortality of tuberculosis
began declining in most of western Europe and North America. This decline
occurred in different places at different times and rates. The industrial pioneers,
England and Belgium, whose mortality rates had risen above 300 (per 100,000),
were the first countries whose rates then fell below that appalling figure: Belgium
in the mid-1860s, England about 1870. (Some places—bucolic Ireland and
Switzerland, thinly settled Australia and New Zealand—may never have been
that high.) Between about 1890 and World War I rates fell below 200, again
chiefly in the most advanced industrial states: Italy in 1891, Belgium in 1892,
England in 1894, the Netherlands and the United States in 1901, Denmark in
1902, Germany in 1906, Scotland in 1909, Switzerland in 1914. In 1921 the mor-
tality rate from tuberculosis dropped below 100 in the United States and
Denmark; the Netherlands followed in 1925, Belgium, England, and Germany in
1926, Scotland in 1928, Italy in 1933, Switzerland in 1935.10
Exceptions to the pattern existed, however. In Ireland the tuberculosis
mortality rate did not peak until the late 1890s, declined only slowly until about
1908, and then—while it fell more rapidly—remained above 100 until after World
Tuberculosis and Poverty 161

War II. Norway’s experience mirrored Ireland’s, although its mortality fell
below 100 by 1937. In east-central Europe—Austria, Hungary, Czechoslovakia—
tuberculosis mortality remained very high (and perhaps even peaked) in the first
decade of the twentieth century, fell below 300 by 1914, surged upward again in
World War I, and then dropped rapidly after the war. But like Ireland they all
remained over 100 until after World War II. In France, something of an anomaly
in western Europe, rates remained well over 200 during World War I and fell
below that number only in 1920.
The decline in the tubercular death rate, accomplished before the dramatic
reductions that followed antibiotic treatments after World War II, poses some of
the thorniest problems in the disease’s history. Those problems are ultimately
those of explanation: did deliberate human measures contribute in some way to
loosening the hold of tuberculosis? If so, how decisive were those interventions?
Or were all such human responses overshadowed by more general changes
in the social and economic condition of the poor? Or did tuberculosis decline
for reasons entirely exogenous to any human actions, whether deliberate or
Because etiological views about tuberculosis remained in conflict for much of
the nineteenth century, disagreement persisted about what possible measures
could have a beneficial effect. As the century went on (and the disease’s mortal-
ity started to fall) many thinkers came to view consumption more clearly as a
social problem, or as the product of social problems, and to tie it less clearly to
romantic sensibilities. Associations of tuberculosis and romantic suffering did
not disappear; the consumptive images of Thérèse de Lisieux (in real life) and
Sarah Bernhardt (on the stage) remained a part of late nineteenth- and early
twentieth-century French conceptions of tuberculosis.11 The romantic view of
the creative, artistic tubercular sufferer persisted outside France as well;
Puccini’s La Bohème was, after all, first performed in 1896. But that opera may
also illustrate the point that more often slums, not literary salons, yielded the
prototypical consumptive. Mimi may have a beautiful voice, and the characters
may live in a creative Latin Quarter, but they are also poor and cannot afford
medical treatment. Tuberculosis might accordingly confer shame, not cachet.
The new perspective almost certainly reflected a more accurate demographic
understanding than the old, for tuberculosis had always been a disease that rav-
aged the poor. But with it came a further burden of stigma, which associated
poverty and tuberculosis in a symbiotic relationship of individual failure.
Nineteenth-century etiological arguments about tuberculosis, centering on
either contagion or heredity, remained uncertain in part because neither expla-
nation seemed entirely satisfactory. Too many members of “consumptive” fami-
lies remained free of disease; descent from a tubercular parent did not inevitably
lead to consumption, and sharing a house with one apparently did not either.
162 The Burdens of Disease

Those circumstances led—naturally enough—to an emphasis on “predisposing”

causes that might explain why the basic cause (be it heredity or contagion) could
overcome the resistance of some and not others.
It might be well at this point to consider modern explanations of tuberculosis.
The causative “germ,” whether M. tuberculosis or M. bovis, lodges in the human
body. Immunological reactions shortly begin, and a walled-off “tubercle” results
that contains the bacillus and prevents its further spread through the body. The
person so infected may now be said to “have” tuberculosis, if by that word is
meant a positive reaction to a tuberculin test; but in many cases no clinical symp-
toms ever develop, so that if the tuberculin test were not administered no
assumption of tuberculosis would ever be made. In some individuals, however—
and here the etiological puzzles arise—the body’s immune systems fail to contain
the spread of the bacillus, and different clinical manifestations of tuberculosis
result, sometimes rapidly, more often much more gradually.
Some people apparently enjoy more resistance to tuberculosis than others.
Their resistance is not to the initial infection, for bacilli make their way into the
body (through either respiration or ingestion) without much interference.
Resistance rather arises when the body’s immunological defenses respond to
the invasion. Many possible variables have been suggested to explain different
powers of resistance. In the nineteenth century “predisposing” causes included
diet, stress, dirt, general bad habits, and—for those who denied the primacy of
one or the other—heredity and contagious contact. In some form modern dis-
cussions still debate some of those causes as possible explanations of varying
tuberculosis mortality and morbidity.
Pulmonary tuberculosis undoubtedly found favorable conditions for spread in
the nineteenth century, in both Europe and North America, if only because of
the rapid increase of population and its dramatic urbanization. Cities grew explo-
sively; more than that, they experienced remarkable congestion, especially in
the earlier decades of urban growth, before the cities began their expansion into
the suburban hinterland. Dwellings crowded together; within dwellings lived
more people per room. Urban and industrial life also meant more crowded work-
places, whether in the factory or in the office. The spread of compulsory school-
ing, and its extension to older age groups of children, promoted congestion in
another setting as well. The sooty and sometimes noxious air that characterized
the early industrial city, especially in those economies fired by coal, may have
increased confined life and discouraged ventilation; who would willingly open a
window to the grime and the smells? All these circumstances increased the like-
lihood of respiratory infection.
And it remains possible that many nineteenth-century city dwellers also
lacked defenses once respiratory infections took hold. Diets, especially of the
urban poor, were high in fats and carbohydrates (yet perhaps low in calories),
Tuberculosis and Poverty 163

low in vitamins and proteins. Sugar (in various forms) supplied a disproportion-
ate and growing share of working-class calories.12 Alcohol consumption was
high; British per capita consumption of spirits was 1.11 gallons per year in 1831,
five times the comparable 1931 figure, while 21.6 gallons of beer were consumed
per capita, also much higher than the 1931 amount.13 Those figures, impressive
as they are, probably understate actual consumption, for they take no account of
extralegal production. French consumption of alcohol, largely wine, may have
been even more formidable than British. Men got a larger portion of food and
drink (for better or for worse) than did women, who were especially likely to be
denied adequate protein and vitamins. As long as urbanization and industrializa-
tion meant a decline in nutrition—if in fact they did—populations may have been
less able to resist the spread of M. tuberculosis within individual human frames.
Stress may have added to dietary weakness. Some modern historians—
following some commentators of the period—have drawn vivid pictures of the
disorientation resulting from moves from village to city, and from agricultural
(or craft) labor to factory work at the pace of a tireless water mill or steam
engine.14 Until the migrants to the cities evolved their own culture, with its net-
work of friends, relatives, and customary social supports, stress may have been
very severe. “Stress” is of course hard to evaluate, especially in the past. The
surge in tuberculosis mortalities that accompanied both World War I and World
War II might have been due to “stress,” but it more likely was produced by the
crowding together of people—troops, internees, prisoners, factory workers—
and resultant heightened chances of contagion that those conflicts afforded.
To assert that the early decades of industrial urbanization were marked by
poor diets, high levels of stress, and a general decline in standards of living, espe-
cially for working people, steps into a historiographic minefield of considerable
power and antiquity. One authority warns that “Any search for a single answer to
the question of what happened to the standard of living [in Great Britain]
between 1700 and 1850 is unrealistic,” and scholars have increasingly focused
their attention on particular components of “standards of living.”15 On the one
hand, some evidence suggests that British wages in the late eighteenth and early
nineteenth centuries may have risen faster than pessimistic estimates assumed,
which if true might reduce the period of industrially related vulnerability to
tuberculosis. 16 But the fact that the average heights of British birth cohorts
declined between 1820 and 1850 suggests that environmental pressure and per-
haps nutrition were unfavorable for health. As Roderick Floud and Bernard
Harris put it, “any wage increases that did occur were bought at a high price in
terms of health and mortality.”17 And many of the “optimistic” wage studies lean
on national aggregates, which (as Maxine Berg and Pat Hudson note about simi-
larly based population estimates) may “conflate opposing tendencies in different
regions, sectors of industry and social groups.”18 Studies of human heights
164 The Burdens of Disease

reinforce that point: urban people were consistently shorter than their rural coun-
terparts, and people of lower socioeconomic status were shorter than those fur-
ther up the scale. A later example may illustrate the dramatic contrasts in
tuberculosis rates that could be found in different sections of the same city. In
1926 the tuberculosis mortality rate in the affluent eighth arrondissement of Paris
was 75, while in the poor thirteenth arrondissement it was 306.19 Clearly poverty
and class mattered, and clearly their significance might be masked by national
The phenomena first seen in Britain played themselves out later in other coun-
tries. British cities grew most rapidly in the first half of the nineteenth century.
French cities—Lyons, Marseilles, Paris—showed their highest rates of growth
between 1850 and 1880; and in the following decades (1880–1910) the cities of
Germany, Austria-Hungary, Russia, Italy, and Scandinavia grew most rapidly
(see Table 8.2). The chronology of industrialization was similar. In France the
period from 1850 to 1875 may have been analogous to 1800–1840 in Britain;
Germany may have followed France by a decade, Italy’s surge occurred at the
end of the century, and Russia’s had hardly begun by the outset of World War I.
Urban overcrowding and the pains of intensive industrial take-off, therefore,
spread their way across Europe, outward from Great Britain and generally from
the northwest to the east and south.
Nineteenth-century thinkers also considered “race” another possible predis-
posing cause, in effect an extension of belief in the power of heredity as an
explanatory principle. Were some social groups, whether of blood or of class,
more prone to consumption? Were the Irish more likely victims simply because
they were Irish? In fact some groups may have been more at risk, and the cir-
cumstances of early industrialization and urbanization—apart from the environ-
ment—may have made them so. The body’s ability to resist tuberculosis, to
contain the invading bacilli in a tubercle, may in part depend on inheritance;
repeated exposure leads to increased powers of resistance and inheritable immu-
nity. Especially in the early decades of industrialization, large migration from
rural areas fueled city population growth. The newcomers moved from areas of
low density and congestion, where tuberculosis bacilli were rarer, to a much
more disease-laden environment. For at least a few generations the immigrants
formed a virgin population for the tuberculosis organisms. Hence the suspicion
that the rural Irish were especially susceptible might have had a basis for a time;
and indeed, the incidence of tuberculosis morbidity and mortality continued to
rise in Ireland down into the early twentieth century, long after it started to
decline in areas that became urban earlier.
Racial explanations of tuberculosis received a particularly strong hearing in
the United States, where the considerable differential between tuberculosis rates
for whites and blacks lent credence to such theories. In 1910, when the national
Tuberculosis and Poverty 165

Table 8.2
Percentage Rates of Urban Growth, 1800–1910

City 1800–1850 1850–1880 1880–1910

Great Britain
Birmingham 230 72 31
Edinburgh 134 52 36
Glasgow 348 70 34
Liverpool 359 47 35
London 140 78 52
Manchester 304 13 109
Lyons 61 112 26
Marseilles 76 85 53
Paris 93 116 27
Germany and Austria
Berlin 144 168 85
Breslau 90 140 88
Cologne 94 50 256
Dresden 62 128 148
Hamburg 2 120 221
Leipzig 110 137 295
Munich 175 109 159
Vienna 80 64 180
Russia and Poland
Moscow 46 68 142
St. Petersburg 121 81 117
Warsaw 0 152 240
Genoa 20 50 51
Milan 42 33 86
Naples 28 10 46
Rome 14 71 80
Turin 73 88 69
Copenhagen 26 85 97
Stockholm 22 82 102

Source: Complied from figures in Carlo M. Cipolla, ed., The Fontana Economic History of Europe,
vol. 4, The Emergence of Industrial Societies (London: Collins, 1973), 750.

tuberculosis mortality rate was 160, American blacks suffered 446 tuberculosis
deaths per 100,000; and while the 1940 figure for African Americans had fallen to
128, the overall rate had then reached 46.20 At the beginning of the twentieth
century, when most African Americans still lived in the largely rural South,
166 The Burdens of Disease

American medical opinion about their health was dominated by the views of
southern physicians, who led the development of theories of “inherited suscepti-
bility,” part of a more general view that Africans were destined to be losers in the
struggles of natural selection. Only slowly, in the early decades of the twentieth
century, did environmental explanations of the high tuberculosis rates among
African Americans make headway against such “genotypical” beliefs.
Congestion, poverty (and the resultant overcrowding and poor nutrition), and
migration of vulnerable rural populations to cities all combined to spur nineteenth-
century increases in tuberculosis incidence. But social and economic change
eventually had ameliorating influences as well. The Victorians came to place great
emphasis on the virtues of fresh air and ventilation, in part because of general
beliefs in the miasmatic origins of some diseases, in part because of dislike of
industrialization itself and a desire (especially strong in Great Britain) to restore
the purer and simpler life of a preindustrial past. The conviction that ventilation in
general benefited health led to assaults on such early urban housing evils as
“back-to-back” construction and cellar dwellings. Gradually cities adopted build-
ing codes, undertook slum eradication, and began providing municipally funded
housing for the poor. Nowhere was the task of slum clearance complete, or
quickly or easily done; the barriers erected by vested interests, demographic pres-
sure, and persistent poverty and unemployment were difficult to overcome.
But it is possible that by the early twentieth century even the urban poor lived
in less congested and better ventilated quarters than they had earlier. In the
more advanced industrial societies at least, city populations were becoming more
suburban, and less dense, by the end of the nineteenth century. The proportion
of greater London’s population that could be called “suburban” rose from
13 percent in 1861 to 25 percent in 1891; in Paris, while the population of the city
proper increased 50 percent between 1861 and 1896, the remainder of the city’s
département grew 203 percent.21 And as industrial economies matured, many—
though certainly not all—of the working class graduated into more highly skilled
trades to service the increasingly sophisticated industrial plant. For these
upwardly mobile workers better wages might translate into better housing; some
statistics suggest that between 1875 and 1910 the proportion of the population of
German cities living in one-room dwellings gradually fell, while the proportion
enjoying two rooms gradually rose.22
Improvements in diet also gradually occurred, a point repeatedly emphasized
by Thomas McKeown in his numerous writings. McKeown, concerned with
explaining the rapid growth of the European population in the nineteenth and
early twentieth centuries, believes improvements in nutrition played the key role
in the reduction of mortality from epidemic disease in general and from tubercu-
losis in particular. The decreasing severity of epidemics in turn accounts for pop-
ulation growth, which McKeown attributes to declining death rates, not increasing
Tuberculosis and Poverty 167

birth rates.23 Some factors certainly lend support to McKeown’s argument.

Total calories available per capita may have increased in Europe over the nine-
teenth century, thanks in part to the spread of potato cultivation and in part to
the opening of rich grain lands elsewhere, especially in North America.
Transoceanic imports of cheap grains, especially in the years after 1870, forced
many European farmers to abandon cereals and turn to fruits, and that circum-
stance (accompanied by the development of preservation businesses such as
canneries) meant greater variety in diets. Some evidence also suggests that by
the end of the century some Europeans (especially in Great Britain) consumed
more meat and fish than they had earlier, perhaps because of improvements in
transportation and preservation. And as Richard Steckel and Roderick Floud
notice, early stages of industrialization did not necessarily result in periods of
declining stature. In countries that industrialized later in the nineteenth century,
the environmental stresses reflected in British (and American) statures might
be counterbalanced by such nutritional gains, and by real improvements in sani-
tation and public health.24
Better nutrition benefited only some, of course; Walter Minchinton, who also
argues a case for general improvements in diet through the nineteenth century,
quickly adds that “throughout these years the very poor were badly fed,” while
alcohol consumption remained high and sugar use continued to increase.25 And
although urbanization and transportation improvements may have promoted
greater dietary variety, the removal of populations from immediate access to the
fresh food supplies of farms had some adverse consequences: the greater the
time consumed by transportation of foods, the greater the loss in nutrient values.
Real questions remain about the degree to which diets improved for the mass of
nineteenth-century Europeans, and those questions may have particular force in
the relations between nutrition and tuberculosis mortality. Direct connections
do not link tuberculosis and dietary deficiencies, as they do for instance with
scurvy; diet may be only one of a number of variables that explain an individual’s
resistance to the effects of the tubercle bacillus.
All arguments about the role of improved social and economic conditions obvi-
ously depend heavily on the actual timing of improvements in standards of liv-
ing, especially for the urban populations. Dating dietary and housing changes for
sufficient numbers of city dwellers may be difficult. F. B. Smith, who dismisses
the active roles of medicine in the reduction of tuberculosis, emphasizes another
point: that in Britain the disease declined meaningfully when the birth rate of the
mass of the population began falling.26 Only then could the working classes bet-
ter their standards of living (specifically their housing and nutrition) and thus
more strongly resist the inroads of tuberculosis. Birth rates in different European
states peaked at different periods in the nineteenth century, but in most cases
(with the exception of Russia and perhaps some of the Hapsburg lands) those
168 The Burdens of Disease

rates were declining by the century’s end. In Germany the birth rate peaked
at 39 births per thousand population per year in the 1870s, and by the period
1911–1913 it had fallen to 28. England and Wales also peaked in the 1870s, at
35.5, and by 1911–1913 the rate there had fallen to 24.2. Italy went from 37.5 in
the 1880s to 32 in 1911–1913; Sweden’s peak, 34.5, had been as early as the 1820s,
and by 1911–1913 had declined to 23.5. The birth rate in France declined steadily
throughout the century; over 30 at the beginning of the century, it had fallen to
19.5 just before World War I.27 Ultimately, then, the incidence of tuberculosis
may have varied directly with the birth rate. But the consistently low French
birth rate and high tuberculosis mortality show the insufficiency of birth-rate
These “standards of living” arguments concentrate on exogenous factors,
certainly nonmedical ones, to explain the declining mortality and morbidity
from tuberculosis that began in the nineteenth century. The exogenous point
of view may also include the argument that tuberculosis rates may follow a cycle
of their own, undisturbed by any human action, medical or social. A relatively
virgin population suddenly exposed—whether by migration of people or
microorganisms—will suffer high rates through several generations. But inher-
ited immunity builds up in the survivors, while (in the best natural selection man-
ner) the particularly susceptible die, perhaps without offspring. In the
increasingly more resistant population the morbidity and mortality rates fall, and
that may have occurred in urban Western civilization between roughly 1860 and

Active Social and Medical Responses

Did conscious human action (medical or otherwise) contribute to falling
tuberculosis mortality rates? Perhaps. In the years between 1850 and World
War II the menace of tuberculosis certainly spurred vigorous and changing
responses, some of them (even such a skeptic as Smith agrees) ultimately impor-
tant in altering the balance between people and the White Plague.
The sanitation movement of the nineteenth century, discussed in the previ-
ous chapter, did not take particular aim at tuberculosis. But many of its emphases
coincided with the uncertain and complex etiological ideas that attempted to
explain consumption. Sanitarians held that a variety of environmental factors,
probably working in combination, produced disease. Tuberculosis was attrib-
uted to a variety of causes: bad air, bad habits, heredity. The sanitation move-
ment made attempts to control such possible tubercular agents as industrial and
civic pollution. Soot and smells discouraged open windows, ventilation, and fresh
air. Studies in the 1890s showed the correlation between high tuberculosis
rates and some especially dusty environments such as those around grinding
machines. Perhaps dirty air, especially air laden with particles, provided the irritant
Tuberculosis and Poverty 169

that provoked the tubercular lesions of the lungs. In addition, the sanitationists’
emphasis on the general reformation of the manners of the lower orders might
have some particular applications to consumption, and some believed that if the
poor suffered from tuberculosis they had only themselves to blame. Who, after
all, produced the dusty and dirty environments?
Other nineteenth-century responses grew from the belief that consumption
was hereditary. As René and Jean Dubos point out, such beliefs were strength-
ened by the recurrence of tuberculosis in prominent families, such as that of the
Brontë sisters, Ralph Waldo Emerson, and Henry David Thoreau.28 The heredi-
tary view gained more credence, however, because of its potential for associa-
tion with class; the poor might be seen as trapped in an inescapable loop,
condemned to consumptive weakness and hence poverty by the inexorable force
of heredity. Such arguments also helped excuse medicine (and society in gen-
eral) from responsibility for a disease that frustrated both explanation and cure.
Hereditarian arguments acquired more scientific varnish in the 1860s and the
1870s, as Darwin’s theory of evolution by natural selection (published in 1859)
fed interest in the importance of inheritance.
These hereditarian beliefs about tuberculosis also coincided with the press-
ing questions of “national health” and “national deterioration” that arose in the
late nineteenth and early twentieth centuries, especially in France and Britain. In
the French case such fears grew out of the disastrous Franco-Prussian War
(1870–71); subsequent French medical and public health efforts seemed
obsessed with the presumed causes of national failure, which included tubercu-
losis, venereal disease, and alcoholism, and strong hereditarian arguments sur-
rounded all three.29 In Britain the “eugenics” movement associated with Francis
Galton (1822–1911) led to ideas about selective breeding that might discourage
the tubercular from conceiving children. Doctors in the 1880s advised many con-
sumptives against marriage, while that decade also saw a rising number of abor-
tions among tubercular women.30 (Although eugenic arguments were thus
employed, women may also have associated pregnancy with “stress,” which sup-
posedly increased one’s susceptibility to tuberculosis.) The embarrassing
Second Boer War of 1899–1902 gave national worry about “deterioration,”
expressed by such thinkers as Karl Pearson, a particular focus.
By the end of the nineteenth century, however, sanatoria had become the most
widely heralded response to the problems of tuberculosis. The enthusiasm for
sanatoria had a number of historic roots; several different establishments might
claim to have been the first tuberculosis sanatorium. For example, in the 1790s
the prominent English Quaker physician and philanthropist John Coakley
Lettsom opened a facility for the victims of scrofula at Margate on the Kent coast,
moved to do so by his observation that fishermen rarely contracted scrofula. In
the conflicting etiological beliefs of the eighteenth century, different consumptive
170 The Burdens of Disease

sufferers followed different advice about what sort of “air” would give relief; many
of the romantic generations made pilgrimages to the south, especially to the
Mediterranean, perhaps for its warmth, perhaps for its sea air. The pure air of
the mountains became more popular by the middle of the nineteenth century; the
Swiss town of Davos acquired a particular cachet for the scrofular and consump-
tive, especially if they could afford the trappings of an expensive resort. Herman
Brehmer, credited by the Duboses with work that “marked the turning point in
the treatment of tuberculosis throughout the world,” opened his tuberculosis
sanatorium at Görbersdorf (Silesia) in 1854.31 Brehmer was convinced that pul-
monary tuberculosis led to progressively weaker circulation, and that exercise in
the fresh air of the mountains could work a cure by reversing the process. After a
time he changed his mind about the virtues of exercise for his consumptive
patients and instead advocated rest, but still in the pure mountain air.
The advocates of sanatoria remained ambivalent for decades about the rela-
tive merits of exercise and rest, although the advocates of rest generally won
more favor. That approach certainly dominated the early sanatoria in the United
States, where Edward Livingston Trudeau popularized the concept. Trudeau,
a young physician, despaired of a cure when he contracted tuberculosis and
moved to the Adirondack Mountains of New York, apparently to live out his years
in a place he loved. The remission of his symptoms convinced him that mountain
air and rest had worked a cure, and he opened the sanatorium that would become
a widely copied model at Saranac Lake in 1884.
Sanatoria appealed for a variety of reasons. If stress exacerbated tuberculosis,
sanatoria provided a respite from the pressures of modern life. If “bad air” caused
consumption, the mountains offered “good air.” In the sanatorium the diet of suf-
ferers could be improved. Generally the sanatoria fed their patients protein-rich
menus, laden with milk, eggs, and meat; at Lawrence Flick’s sanatorium at White
Haven, in Pennsylvania, the superintendent reported (in 1901) that “one man
had 17 glass [sic] milk and 8 raw eggs yesterday and another 14 and 8,” and that
“all who take 15 glasses are allowed a cup of tea for supper.”32 Interest in the
virtues of the sanatoria related to the profound anti-urban and anti-industrial sen-
timent that existed in the nineteenth century; the influence of cities, the homes
of dirt, drink, disease, and depraved habits, could be overcome in the pure Alpine
or Adirondack air, where protein could be supplied in heroic quantities and a
vigilant staff could correct bad habits of work and life.
The doctrine of contagion lent other strengths to the sanatorium movement.
Some of the pioneer advocates of sanatoria were deeply convinced of its truth,
even before bacteriological arguments emerged that called the multicausal expla-
nations of the sanitationists into question. A mechanism for tubercular contagion
became clearer in the 1860s when Jean-Antoine Villemin transferred tubercles,
and with them disease, from one animal to another and even from one species to
Tuberculosis and Poverty 171

another. Robert Koch (1843–1910)—who will receive more complete discussion

in Chapter Ten—presented a thorough “history” of the tubercle bacillus in 1882,
which seemed (at least to some) to provide a convincing path of contagion for
tuberculosis. Following his “postulates,” Koch removed such tubercle bacilli
from a sick animal’s tissues, grew a separate culture of the bacilli, and then intro-
duced them into a healthy animal and made it sick. But contagion, despite this
impressive demonstration, remained a controversial idea in the field of tubercu-
losis as well as that of cholera (see Chapter Seven), for it denied the many causes
that sanitationism addressed.
The political implications of contagion theory seemed unpalatable, especially
to the liberal temperament and ideology of the nineteenth century. Tuberculosis
presented particularly serious political issues both because of its wide extent and
because of its chronic character. If contagion were accepted, tuberculosis
victims—many thousands of them—might have to be isolated for years, at enor-
mous cost. Would the enlightened modern age revert to the medieval leprosaria?
Who would pay for them? Leprosy provided frightening parallels as another
chronic disease, believed contagious, whose victims were not just isolated but
stigmatized. Could consumptives be trusted with useful work? If so, how to make
the workplace safe for others? Would families lose their places in community
and society, perhaps unfairly? In addition to these very old objections to conta-
gion, other opposition arose from the contemporary social and political position
of physicians, increasingly sensitive and jealous of their professional preroga-
tives. Would contagion policy, mandating notification and isolation, take author-
ity out of their hands and place it with public health officers, creatures of a state
bureaucracy? Would physicians be required to report cases of tuberculosis to
public authorities? If so, the patient’s trust in the confidentiality of her physician
would shatter. The interference of public officials further implied that someone
other than the physician knew what was best for an individual patient, a notion
becoming increasingly offensive to physicians as their professional power and
self-confidence grew. Little wonder, then, that many physicians insisted, long
after Koch’s supposedly conclusive demonstration in 1882, that Koch’s bacilli
might be only a secondary cause of a disease whose true origin lay in heredity,
bad air, dirt, or irritation of the lung tissue.
These different anticontagionist arguments especially appealed to physicians
and officials in France, where sanatoria did not flourish. French opinion
remained strongly attached to a multicausal approach to public health, especially
as it related to the supposed causes of national decline (tuberculosis, venereal
disease, and alcoholism). Regarding tuberculosis as a simple product of a
microorganism denied the importance of many public health measures; it also
meant acceding to a “German” theory, and both Koch’s bacillus and sanatoria
were tarred by the same xenophobic brush.33
172 The Burdens of Disease

But the contagion theory made headway, and in doing so provided another
raison d’être for the sanatorium: to segregate the sick from the healthy.
And those who did not accept the centrality of the contagion doctrine might find
still other reasons for solving the tuberculosis problem with the sanatorium.
Those who took a moral view of the disease could seize the opportunity to reform
the habits of the patients, which might be a desirable middle-class goal regard-
less of etiological theory. The virtues of exercise remained dubious, but for some
sanatoria directors “graduated labor” would supposedly stimulate “inoculation of
patients by their own bacterial products,” as well as prevent working-class patients
from becoming lazy and losing the habit of work in the restful atmosphere of the
sanatorium.34 Linda Bryder paints a dismal picture of life in British sanatoria in
the early twentieth century. The sanatorium was a “total institution” not unlike a
prison, in which patients lived lonely and isolated lives, rejected by the local pop-
ulation. Superintendents imposed strict discipline, especially regarding contact
between the sexes and the consumption of alcohol, and they dismissed patients’
complaints (about unpalatable food or uncomfortable quarters) as further symp-
toms of disease. When one patient exercised his right to leave, his sanatorium
superintendent remarked, “Tell your widow to send us a postcard.”35
In Britain the disciplinary aspect of the sanatorium had, in any case, been
anticipated by another institution: the workhouse. In 1834 the British Parliament
had ordered a reform of the system of public relief of the poor. From that date
forward—at least in theory—those poor in need of public relief could receive it
only by residence in a “workhouse,” where conditions might discourage applica-
tions from all but those in genuine need of assistance. Among those in genuine
need might be numbered the sick poor, and as the nineteenth century wore on
workhouses under public control came to approximate public hospitals, in which
a high proportion of the patients suffered from tuberculosis, a wasting, chronic
disease that made work (and hence self-sufficiency) difficult.36
Certainly both sanatoria and workhouses, as well as the tuberculosis dispen-
saries that spread rapidly in Britain after about 1909, proved powerful instruments
for intruding into the private lives of individuals, as did home visits and “march
pasts” conducted by public health authorities and nurses. Barbara Bates, a recent
student of early American sanatoria, describes the rugged regimen and spartan
existence they imposed on their patients. She also notes that sanatorium directors
had to keep business considerations in mind: one physician was “desirous that
the summer boarders about to arrive shall not find . . . patients who have been
here so many months without being cured, as it would be a discouragement to
them. It is simply a matter of business and convenience.”37 Really ill patients
should therefore be discharged. Did patients carry changed routines—of sobri-
ety, fresh air, bathing—into their everyday post-sanatorium lives? Bryder thinks
not; more likely they developed anger, both at the officious behavior of their
Tuberculosis and Poverty 173

keepers and at the stigma assigned them by contagionist (or hereditarian) fears.
The other close student of British sanatoria, F. B. Smith, concurs.
But while habits may not have been changed by institutional discipline, facili-
ties such as workhouses and sanatoria did isolate consumptives from the rest of
the population. Leonard Wilson, strongly dissenting from McKeown’s views that
direct human agency had little to do with the reduction of tuberculosis mortality
before World War II, argues that the isolation of poor consumptives in British
workhouses was crucial. Adopting the early twentieth-century views of Arthur
Newsholme, Wilson presents a case that questions McKeown’s evidence and
thus the conclusions of social historians such as Bryder and Smith who in effect
accept McKeown’s arguments about the inefficacy of conscious human response.
Enough poor consumptives were isolated to make a difference, Wilson main-
tains, and their isolation coincides chronologically with declines in British tuber-
culosis mortality.38
Unresolved questions remain, however. Were enough British poor immured
in workhouses to make enough of a difference in mortality rates? The evidence
of the effectiveness of the 1834 workhouse system is very spotty indeed; the cus-
tom of “outdoor” relief, awarded to applicants outside the workhouse, did not
end after 1834. Anne Digby’s study of the administration of the poor law in
Norfolk suggests the continuing problems. She argues that in 1870 “two-thirds
of the sick poor in England and Wales were [still] treated in their homes,” and
that “as late as 1896 only eight Norfolk unions [out of twenty-two] had separate
infirmaries or infectious wards.”39
In addition, Wilson argues that the British workhouse position was unique,
which explains why Britain led the way in declining mortality. German rates
started to fall in the 1880s, following the rapid acceptance of Koch’s theories by
German opinion and the subsequent acceptance of the necessity of isolation. But
how is the Belgian situation to be explained, since if anything the initial mortality
decline there preceded that of the British?
Wilson’s argument also assumes that the reduction in mortality was the result
of a reduction in infections, made possible by isolating the healthy from the sick.
But some evidence also suggests that even after tuberculosis mortality fell, infec-
tion rates remained high. In 1909 von Pirquet applied Koch’s tuberculin test to
1,100 Viennese children, none of whom showed any clinical signs of tuberculo-
sis; 70 percent of them tested positive anyway, so that a high proportion had at
least been infected by their tenth birthday.40 Even later, at a time and in a place
where mortality had fallen more dramatically, tuberculin tests were given to
overwhelmingly middle-class American college students in the middle 1930s.
Results varied widely from one college to another, but of over 12,000 male
students tested, about 39 percent were positive; about 33 percent of 6,600 women
were positive as well.41 Had a reduction in mortality followed a reduction in
174 The Burdens of Disease

infection, as Wilson assumes? Or had it followed an increase in resistance to the

In Britain the enthusiasm for sanatoria began to wane after about 1920, partly
because their benefit was difficult to demonstrate; as Smith argues, measuring
their rates of successful cure remained guesswork, largely because of the chron-
ically elusive character of pulmonary tuberculosis. A sufferer might be released
from an institution “free” of consumptive symptoms, but how long would she
remain so? Could the sanatoria keep track of their former patients at all? Bates,
reflecting on American evidence, raises still other doubts about the effectiveness
of sanatoria. At the least, since all the sanatoria advocates and proprietors had
interested motives, the data they supplied must be suspect.42 Despite those ques-
tions, sanatoria did not so much vanish as lose their position as society’s princi-
pal response to tuberculosis, except perhaps in the United States and Germany,
where sanatoria had taken a particularly strong hold. In the 1920s other reme-
dies and responses appeared, which seemed to make the sanatoria obsolete:
chemical remedies, surgical procedures, a growing attack on milk-based tuber-
culosis and M. bovis, and continuing efforts to find a vaccine that would prevent
the disease or even cure it.
In the nineteenth century tuberculosis attracted a wide variety of nostrums,
and that often bizarre collection of remedies persisted and even extended in the
early twentieth century. Some were offered by quacks, others by legitimate med-
ical practice; of the latter, a variety of gold salts became particularly popular in
the 1920s and 1930s, while vaccines remained controversial. Smith makes an
interesting point: that quack remedies and treatments found special favor with
women, especially with domestic servants, whose fear of dismissal (and whose
working hours and poverty as well) prevented them from seeking orthodox med-
ical advice.43 And quack remedies may have avoided some hazardous side
effects, which could not be said of “gold therapy.”
Surgeons, filled with new confidence in the late nineteenth century as a result
of the successful application of anesthesia and antiseptic methods (see Chapter
Ten), also advanced claims to cure tuberculosis. In the 1880s the Italian surgeon
Carlo Forlanini pioneered the technique of lung collapse, in which a gas (or air)
was injected into the chest cavity between the lung and the chest wall, thus
collapsing the lung. Believing that this procedure would allow the infected lung
to rest, other surgeons gradually adopted it; by the 1920s and 1930s lung-
collapse therapy was another popular and self-consciously “modern” treatment,
in addition to (or instead of) gold salts. Other more dramatic surgery appeared
as well, notably the removal of infected lobes of the lung, or even of the entire
lung itself.
In addition to providing ammunition for the sanatorium movement, Koch’s
“germ” explanation of tuberculosis gave rise to vigorous campaigns against
Tuberculosis and Poverty 175

public spitting, conducted by both voluntary societies and governments. It also

inspired a hope that a vaccine might be found. By laboratory manipulations of
cultures of the microorganism, some dosage or concentration might be found
that would immunize the subject from future infection (as did “vaccination”
proper, with smallpox), or would actually counter the effects of an infection
already under way (as—apparently—did Pasteur’s treatment for rabies, to be
discussed in Chapter Ten). By 1890 Koch’s laboratory had produced such a sub-
stance for tuberculosis, called tuberculin and hailed as a great triumph of mod-
ern scientific medicine when it appeared. Koch believed that tuberculin could
act as a cure for tuberculosis, at least in certain of the disease’s stages. Finding
which stage proved a problem, for at some points the use of tuberculin proved
rapidly fatal. Although tuberculin ultimately failed as a cure, it proved diagnosti-
cally useful. Skin reactions to tuberculin demonstrated whether a person had
previously been infected by the tubercle bacillus.
A preventive vaccine developed from the bacillus was clearly another goal of
this heroic age of bacteriology. The most celebrated of these appeared in its ini-
tial guise in 1906, the product of two Pasteur disciples, Albert Calmette and
Camille Guérin. Their vaccine, an attenuated strain of M. bovis, acquired the
name of Bacille-Calmette-Guérin, and was generally called BCG. It had a very
controversial history. For some years Calmette and Guérin experimented with
the inoculation of different animals, especially cattle. In 1922 they began admin-
istering BCG to humans, and its use spread widely in France, Poland, Spain,
Scandinavia, and Quebec (Canada)—mostly places where French cultural influ-
ences were strong. It met resistance in other countries, notably in Great Britain,
where (as Smith and Bryder agree) physicians specializing in tuberculosis did
not want their routines disturbed and so raised clouds of objections to it.
Adopting the vaccine would pose administrative difficulties; the patients wouldn’t
like it anyway; the quality control and standardization of the vaccine were untrust-
worthy. Then in 1930 a disaster occurred that strengthened the opponents’ case.
Seventy-one of 323 babies in the German city of Lübeck died (and many others
became gravely ill) after being inoculated with “BCG” (actually a heavy dose of
tubercle bacilli), and a predictable outcry against the vaccine arose.44 Despite its
impressive statistical success in the countries that used BCG, its opponents con-
tinued to distrust it until the 1950s, by which time other and more dramatic
weapons—antibiotics—had come into use.
Another important preventive approach developed in the early twentieth
century as concern with bovine tuberculosis grew. Villemin, in the tradition of
very old associations between human and animal diseases, had inoculated tuber-
culosis from one species to another in the 1860s. A few others followed such
connections, and then in the 1890s the American Theobald Smith clearly isolated
M. bovis and showed its differences from M. tuberculosis. But what degrees
176 The Burdens of Disease

of immunity from, or resistance to, different bacterial species did different

animals enjoy? Were humans little affected—or not affected at all—by bovine
tuberculosis? Could human tuberculosis be regularly transmitted to cattle?
In 1901 Koch lent his great prestige to the belief that the animal tuberculosis
could not infect humans, and vice versa, but that declaration ran counter to the
assumptions of existing public health advocates, who had commenced a zealous
attack on infected milk and meat as part of their broad-fronted war on multicausal
tuberculosis.45 In 1911 a British Royal Commission agreed that Koch had been
mistaken and that milk from tuberculous cattle posed a danger to humans who
consumed it.
That belief now joined hands with practices already under way. Pasteur, back
in the 1860s, had shown that microorganisms caused fermentation and the
accompanying souring of milk (and of wine), and that such living agents of fer-
mentation could be killed by heat. Would the same heat also kill M. bovis? The
process of heating, “pasteurization,” initially undertaken to prevent the souring
of milk (and the conversion of wine to vinegar), slowly spread as a method of
cutting the transmission of bovine tuberculosis to humans.
Resistance to pasteurization of milk could be substantial, sometimes stem-
ming from simple conservatism of habits and such important cultural issues as
the “taste” of the milk, and sometimes from more directly vested interests of
dairymen and even some physicians. Likewise, attempts to eliminate tubercular
cattle threatened important interests, for landowners and farmers still wielded
much political and economic power in most countries. Tuberculin tests revealed
that (for example) between 20 and 30 percent of the cattle population of the east-
ern United States were infected; did eradication of bovine tuberculosis mean the
slaughter of millions of beasts?46 Agricultural interests rose up in fear (as they
did again in the British bovine spongiform encephalopathy crisis in the 1990s),
and taxpayers faced huge compensation claims if a government decreed such a
massacre in the name of public health. Different American states individually
began various measures in the 1890s, involving banning the importation of
infected breeding cattle, free tuberculin testing, and some compensation to farm-
ers who agreed to the destruction of tubercular animals; but the expense of such
programs, especially in light of Koch’s dismissal of the menace of bovine tuber-
culosis, brought many of them to a halt.
But the 1911 British report symbolized a change of views. In the United States
a remarkable display of the power of the gospels of public health and scientific
medicine followed, in which the acolytes of those gospels were aided by cultural
assumptions about milk; “clean milk carried a freight of meanings,” as Barbara
Rosenkrantz puts it.47 So inspired, a vast and largely successful federal campaign
to destroy tubercular cattle began in 1917. In five years the incidence of tubercu-
losis in American children was one-half that in their British counterparts,
Tuberculosis and Poverty 177

although the causal connections between that fact and the cattle campaign
remain murky. In Scandinavia similar success was attained not by slaughtering
infected animals, but by the more labor-intensive system of isolating them from
contact with others. In Britain political resistance to either the American or
Scandinavian systems proved much stronger, and rates of nonpulmonary tuber-
culosis (such as scrofula) remained much higher there throughout the 1920s
and 1930s. F. B. Smith, calling this a “massive waste of national resources,” adds
that the tuberculosis rate in British children would have been even higher if
British milk consumption had rivaled American.48 Perhaps for the same reason—
low per capita milk consumption—bovine tuberculosis remained a less serious
issue in southern Europe.
Reducing bovine tuberculosis and its spread to humans, both through pas-
teurizing milk and through culling of infected herds, may have accounted for
some decline in tuberculosis rates, but only after about 1920, only in some places,
and not in respect of pulmonary tuberculosis. Vaccines, notably BCG, likewise
had no effect before the 1920s, and thereafter only locally. The sanatoria—and
such other systems of isolation as the British workhouse infirmary—certainly
spread earlier, but their impact on tuberculosis morbidity and mortality remains
unclear, both because much of their regimen seems of dubious value and
because they touched only a minority of tuberculosis victims. Sanatoria (and
workhouses) did more or less effectively isolate tubercular patients, and so they
reduced the chances of continued contagion. When surer techniques of diagno-
sis developed in the early twentieth century—first the tuberculin test and then
the chest X-ray—the utility of sanatoria as isolation wards increased; but those
diagnoses, and effective isolation, followed the decline in tuberculosis incidence
that was already long under way.
Much of the explanation of that decline, which began in the nineteenth cen-
tury, therefore necessarily relies on environmental and social changes. The reg-
ulation of workplaces, beginning first in Great Britain in the 1870s, led to the
required use of masks and the provision of ventilation, particularly in such indus-
trial dust environments as stone-cutting, brass-working, and abrasives-making.
More important, housing improved after the horror-filled first generation of
industrial cities; homes became more spacious and sanitary, even if only margin-
ally so. Gillian Cronje has suggested that such improvements in housing may
account for the more rapid decline in tuberculosis incidence among women that
characterized Britain after about 1860.49 It may be more difficult to make a case
for improved diets among the nineteenth-century working classes, but reduced
birth rates certainly made several important contributions: healthier women,
healthier babies, greater possibility of improving a family’s standard of housing
and diet alike, perhaps less stress. It is therefore likely that the decline in inci-
dence of tuberculosis in the second half of the nineteenth century was chiefly
178 The Burdens of Disease

caused by increasing individual powers of resistance, for which several environ-

mental and social factors must receive credit.
Those individual powers of resistance may have been further strengthened
by heredity, as exposure stimulated antibody activity in successive generations.
And as the number of clinical cases began to decline, so too did the number of
contagious agents in the population; by the twentieth century the proportion of
the population infected (whether “clinically” or not) also began to fall, meaning a
further decline in clinically observed cases. When to the deliberate medical
ameliorations of the 1920s and 1930s were added the remarkable effects of antibi-
otics (especially that of streptomycin) in the years after World War II, tuberculo-
sis retreated even further.
That apparent conquest of tuberculosis will receive more discussion in
Chapter Eleven. But I should here note that the rhythms of rising and falling
tuberculosis incidence continue. Persistent poverty and urban overcrowding
combine with rapid international and intercontinental migration to bring little-
exposed populations into new and dense urban contact. For example, the inci-
dence of tuberculosis rose again in the United States between 1985 and 1993,
and while that increase has subsequently been reversed, tuberculosis (including
new strains resistant to antibiotics) now makes its way in populations across the
world whose inherited powers of resistance may have atrophied or whose entire
immune systems may have been compromised.

Disease, Medicine, and

Western Imperialism

B y the end of the nineteenth century Europeans had achieved an

unprecedented mastery of the rest of the globe. This mastery included a remark-
able expansion of the area settled by Europeans, the extension of European trade
and transportation routes to all corners of the earth, and the imposition of
European control (of different sorts) on almost all land areas not actually settled
by Europeans and their descendants. All of those aspects of European domina-
tion had important consequences for the history of disease, its diffusion, and its
effects on different world communities, including their ability to resist the con-
tinuing spread of Western power and influence. Although in some respects that
European dominance had begun in the sixteenth century, its most dramatic
manifestations occurred in the nineteenth, and so this chapter largely concerns
the “long nineteenth” century between the French Revolution (1789) and
World War I (1914).
In the course of that century the world’s population literally became more
European. The percentages may seem insignificant, but they reveal an interest-
ing shift in the world’s balance of population power. In 1800 Europe contained
about 21 percent of the world’s people; by 1900 the proportion had risen to about
25 percent. In raw numbers Europeans had more than doubled in those hundred
years, growing from about 187 million to about 400 million. Much of that increase
occurred in the second half of the century, for in 1850 the Europeans still num-
bered only 266 million.1 This remarkable surge of population was even more dra-
matic than those numbers suggest, for while Europe’s population grew it also
sent forth millions of others; during the nineteenth century perhaps thirty-five
million Europeans left their native continent to settle permanently elsewhere,
the great majority of them leaving after about 1840. This swarming of Europeans

180 The Burdens of Disease

created large areas of the world in which Europeans and their descendants con-
stituted a substantial or even overwhelming majority of the populations, as was
true of the United States, Canada, Argentina, Australia, New Zealand, and
Uruguay. Substantial European communities settled elsewhere as well, some-
times (as in South Africa) maintaining themselves segregated from other inhabi-
tants, at other times (as in Brazil and elsewhere in South and Central America)
intermingling with peoples both American and African. For European domina-
tion of the world did not simply mean the migration of Europeans; it also meant
the massive transplantation of other peoples, in some cases forcibly, in others
voluntarily, from one continent to another in response to European-directed
demands for productive labor. The most obvious example was, of course, the
monstrous traffic in slaves from Africa (largely its west coast) to the Americas,
which began in the sixteenth century and continued into the nineteenth. But as a
combination of conscience and self-interest drove Europeans (and their
American descendants) to abandon that nefarious trade in the nineteenth cen-
tury, other significant movements of people occurred, often motivated by
European demands for labor. Thus the modern states of Fiji, Guyana, Mauritius,
South Africa, Surinam, and Trinidad have large populations of South Asian
descent. And within both Africa and Asia large internal migrations also
responded to European labor demands.
These movements were accomplished with much greater speed and ease by
the end of the nineteenth century than at any previous time, and for that facility
of movement the steam engine was largely responsible. Steam railways revolu-
tionized land travel with both their speed and their reliability. Much of their early
construction was in Europe and North America, which in 1840 had over 98 per-
cent of the world’s mileage; nearly 80 percent was in Britain and the United
States.2 And while much railway building occurred in other continents later in
the century, the effects of the railway remained greatest in Europe and areas
(Australia, Canada, Argentina, the United States) dominated by European immi-
grants. In those places the railway spread settlement, sped the exploitation of
natural resources, and moved food supplies in a way that leveled the ancient
regional imbalances (and resulting local famines) that had characterized earlier
Western (and every other) history. Effects on nutrition and hence on health were
complex. Movement of food to different areas became easier, and so both quan-
tity and variety of foodstuffs can only have improved (at least in theory). But
while large populations in cities may now have been supported by adequate calo-
ries, they might also receive inadequately preserved goods that had either lost
some of their food value or become infected by harmful molds in the course of
storage and transport. Outside areas of European settlement, railways may have
had less impact on the disease pattern, although in India extensive railway
construction did contribute to unifying that subcontinent’s biological systems.
Disease, Medicine, and Western Imperialism 181

In Africa and much of the rest of Asia and South America, railways affected dis-
ease more by contributing to larger social and economic dislocations.
The steamship may have had more immediate importance for moving dis-
eases, their vectors, and their victims to virgin territory. Until the 1860s the sail-
ing ship held its own, but after that decade the weight of a combination of new
technologies made the steamship economically superior. The iron hull, such as
that of the pioneering Great Britain (1843), allowed ships to surpass the struc-
tural limits on size that wood construction imposed, and it also permitted the
design of ships whose lengths (in proportion to their beams) were far greater.
Greater speed resulted, especially with the application of the screw propeller
(the Great Britain again) and the compound steam engine. For example,
steamships so equipped traveled from England to Mauritius in 1865 without refu-
eling.3 Multiple propellers, triple (or even quadruple) expansion steam engines,
and steel hulls, all in use by century’s end, added to the steamship’s advantages.
A sailing ship’s voyage across the Atlantic might vary considerably; in the mid-
dle of the nineteenth century an average sailing packet might make the crossing
eastbound in three weeks, with the westbound voyage slower. The first
steamship crossings in 1838 were accomplished (westbound) in eighteen and fif-
teen days, and by 1879 the crossing had fallen to seven days.4 In the sixteenth
century the movement of smallpox across the Atlantic by sailing ship may have
depended on a tragic combination of difficult to predict circumstances, but the
late nineteenth-century steamship made the transfer of plague from the coast of
China to much of the rest of the world a dramatic certainty.
Europeans increasingly exercised both political and economic control over
the world in which they had revolutionized transportation. The extent of Western
political control in other continents, imposing in 1850, had become breathtaking
by 1900, when nearly the entire land area of the globe was claimed and controlled
by Europeans or their American descendants; only Ethiopia, Liberia, Turkey,
Persia, China, Japan, and Siam maintained independence, and in some of those
cases the claim was more titular than actual. European flags flew over most of
Africa, South, Southeast, and Central Asia, and all of Oceania. European eco-
nomic domination was perhaps even more impressive, extending as it did into
the reaches of even the nominally independent states; Bernard Porter observes
with some justice that politically independent Argentina was “as much a British
‘colony’ as Canada,” and was “Britain’s perfect satellite economy: a willing
servant who did not need to be enslaved.”5 The Western world was the source
of the overwhelming bulk of foreign investment in the nineteenth century; at
the outbreak of World War I Britain, France, and Germany alone accounted for
76.7 percent of the world’s foreign investments (a number that would fall to
50 percent by 1938). In 1850 92.5 percent of the world’s registered shipping
(admittedly incomplete figures) carried either European or American flags, and
182 The Burdens of Disease

in 1913 that percentage was still 90.5. This shipping symbolized a domination of
world trade in general: 78 percent of such trade in 1840 was in European hands,
80 percent in 1880, and still 69 percent in 1913.6
European travel and settlement, the reshaping of non-Western societies by
European political and economic influence, and the revolutionary impact of
Western transport on international and transoceanic intercourse all had numer-
ous and important consequences for the world’s disease history. By the end of
the nineteenth century most Westerners regarded their impact on world disease
complacently or even proudly. Where Western trade and conquest went, so also
went Western science and medicine. Especially after the power of the germ the-
ory asserted itself in the last two decades of the nineteenth century, Westerners
were convinced that they could master the diseases of the world, at least for their
own benefit (enabling them to settle or reside where they chose), and perhaps
for the natives’ preservation as well. Western medicine, and its power over dis-
ease, became a justification for the expansion of Western imperial power and an
illustration of the superiority of Western culture. Subsequent medical history
agreed, focusing on the triumphs of Western biomedicine and sanitation over
“tropical diseases” such as malaria, yellow fever, and cholera.
More recent scholarship has argued that the relations between Western
expansion and the world’s disease history were far more complex than that sug-
gested by a simple model of enlightenment extending into darkness. Some writ-
ers have seen the power of Western medicine as a “tool of empire” (in Daniel
Headrick’s phrase), which made possible penetration and settlement in areas
previously closed to Europeans by disease barriers and enabled European
employers to keep native work forces healthy. Thus Philip Curtin has shown that
European troops, for whom assignment to the tropics was earlier a sentence of
death, benefited from a “revolution in tropical medicine and hygiene.”7 A more
subtle version of the “tools of empire” argument focuses on the ways in which
medicine became part of the West’s assertion of cultural supremacy, an assertion
sometimes accepted by non-Western peoples as well. David Arnold summarizes
such points: disease enabled Western colonial powers to contrast their science
with the “fatalism, superstition and barbarity of indigenous responses”; western
“tropical medicine” became a specialty that studied primitive environments, and
disease proved the social and moral inferiority of non-Westerners.8 Western med-
ical power could convince the indigenes of their own inferiority; thus Western
medical ideas displaced the traditional practices of healing in Tunisia.9
Another view of Western biomedicine simply rejects any notion of “triumph”
altogether, arguing instead that Western expansion and domination in the nine-
teenth century meant new opportunities for the spread of disease; far from a
triumph, Western imperialism was a disaster in disease history. Certainly the
Disease, Medicine, and Western Imperialism 183

expansion of Europeans brought them into more frequent contact with diseases
that they had previously rarely met, and faster transportation made the transmis-
sion of those diseases back to Europe and North America more certain. Diseases
could travel both ways in the nineteenth century as well as in the sixteenth, so
that Europeans brought their diseases to other parts of the world too. And per-
haps more important, when Westerners made the world their common ground
they facilitated the movement of disease in many ways. Western conquest, colo-
nization, and development might impose changes on physical infrastructure that
not only facilitated the movement of disease but created new (and perhaps more
favorable) environments for disease vectors. Conquest itself often meant mili-
tary occupation, which brought both venereal disease and the conquerers’ con-
cern with the health of their troops. Conquest and economic development or
exploitation resulted in the movement of people to new locations where they met
new microorganisms, were subjected to the disease stresses of an urban area, or
found their resistance weakened by difficult working conditions.
In some ways Western colonial powers responded vigorously to diseases in
their overseas territories, but their motives for doing so were mixed and the
vigor of their responses varied widely. They certainly desired to protect Western
troops and administrators from the ravages of disease; they hoped to maintain
the health and thus the productivity of the native work force; they wished to
deflect international criticism from the more sordid aspects of empire. Many
Westerners held deep humanitarian convictions, which they joined with a faith
in the efficacy of Western science and medicine to improve lives. But in other
ways, scientific medicine provided a vehicle for thorough social and political con-
trol of fractious colonies. And the sense persisted that Western lives mattered
more than those of the subject peoples; if wars on disease threatened to cost too
much, the health of the “natives” might be ignored.
In fact both the “triumph” and the “disaster” schools overstate their cases. At
least until World War I biomedicine and sanitation had only inconsistent success
against yellow fever, malaria, plague, and cholera. By the late twentieth century
some of the subsequent successes began to seem temporary, as Chapter Eleven
will show. Certainly Western influence changed disease environments, often for
the worse, but sometimes for the better. And just as the effects of Western bio-
medicine on disease fell short of some enthusiastic claims, so too did the use of
medicine as a “tool of empire.” Western assertions of medical superiority bol-
stered many egos and helped shape “constructions” of non-Western societies,
but those non-Western societies and indigenous healing systems were some-
times more resilient than they appeared. Lack of resources, or internal conflicts
and contradictions in goals, sometimes frustrated Western intentions to reform a
colonial disease environment.
184 The Burdens of Disease

Europeans Bend the Disease Environment

The improved means of European travel soon proved their power as
facilitators of disease. And just as it did in the fourteenth century, plague afforded
a dramatic example of a disease in motion along human trade routes. As its
fourteenth-century march had proceeded slowly across land and then jumped by
sea from the Crimea to Sicily, so the nineteenth-century pandemic crept across
Asia and then—carried by steamship—spread over the world in a few years.
After its waning in Europe in the late seventeenth century, plague had
remained or became endemic in several portions of Asia, including (by the late
eighteenth century at the latest) the Chinese province of Yunnan, which under-
went considerable urbanization in the early nineteenth century.10 The great
Muslim rebellion that began in 1855 resulted in nearly two decades of internal
turmoil in Yunnan, in which plague epidemics coincided with military massacres,
famine, and considerable emigration. Although troop movements and emigration
may have spread plague to other areas of China, trade routes were decisive in the
more rapid diffusion of the disease. Opium and tin moved from Yunnan to coastal
points only very slowly, but plague spread along those routes in the years between
the rebellion and the 1880s; the disease reached Beihai, on the Gulf of Tonkin
coast, by 1867. Then in the late 1880s the steamship intervened, replacing the
slow junks that had moved goods along the Chinese coast. Towns near
Guangzhou (Canton) were infected in 1892, and in 1894 plague broke out in both
Guangzhou and neighboring Hong Kong. In Canton about 40,000 people died of
plague in four months of 1894, while an unofficial observer estimated 12,000
deaths in Hong Kong by 1895.11 From those international ports the disease spread
rapidly both along the Chinese coast and to other places, especially savaging
India, where six million people died of plague between 1896 and 1908. Plague
reached Madagascar in 1898, and a reservoir of infected rodents quickly became
established there; that island nation has had plague deaths annually since.
By 1899 plague had spread to such distant points as Honolulu, San Francisco,
Egypt, and Paraguay, with steamships the efficient conveyers of the microorgan-
ism and its vectors. In Honolulu plague especially affected the Chinese quarter, a
large part of which was destroyed when the burning of infected houses got out
of control.12 In San Francisco plague arrived on the same ship that had earlier
brought it to Honolulu; although that ship arrived in June 1899 (with plague
aboard), no further cases appeared in the city until September 1900, suggesting
that plague had first moved from the infected ship to the city’s rodent popula-
tion. Plague’s appearance among the city’s people precipitated “one of the most
scandalous events in the history of U.S. public health.” When the Board of Health
ordered a sanitary cordon around the city’s Chinatown, business interests and
some newspapers denounced the very idea that plague could be in the city; the
governor of California, Henry Gage, called it a “scare” and proposed that “it be
Disease, Medicine, and Western Imperialism 185

made a felony to broadcast the presence of plague.”13 A major political struggle

ensued, with the Board of Health and city government, most doctors, and the
university medical schools lined up against the governor, most merchants and
newspapers, rail and shipping interests, and the Chinese population, all of whom
denied the presence of plague. In 1901 a federal commission was appointed to
override the state government and force a disinfection of the Chinese parts of
the city. (Californian capacity for denial persisted. When plague broke out in the
Mexican district of Los Angeles in 1924 the city’s newspapers called the disease
“malignant pneumonia.”)14
Among the places that plague reached (in 1899) was Japan, whose nineteenth-
century history well illustrates the power of Western pressure and steam trans-
portation. Japan seemed relatively free of a number of diseases down to the
middle of the nineteenth century. Although it was not entirely isolated from trade
with other Asian countries in the Tokugawa period, as an island state it enjoyed a
natural cordon sanitaire, and its governors tightly controlled the few ports of
entry. No evidence of plague in Japan has been found before 1899; Ann Bowman
Jannetta points out that Japan, unlike mainland Asia, was not on the caravan
routes that had been the traditional means of diffusing plague. But when “a com-
modity trade . . . linked infected Chinese ports with Japanese ports, we have clear
evidence of plague in Japan.”15 Japanese isolation had also kept typhus out and
cholera at bay. Jannetta finds no evidence of typhus before the 1890s, and indeed
the Japanese language had no word for it. Cholera did reach Japan in 1822, as
part of its first spread from India, but when that outbreak died out Japanese quar-
antines held the fearsome visitor away in the years of the 1830s and 1840s when
it so impressed the Western world. The collapse of Japanese isolation, in the face
of American and other Western pressure in the 1850s, opened the way for a seri-
ous cholera epidemic in 1861–62.
The islands of Oceania experienced the clearest episodes of “virgin soil” dis-
eases in the nineteenth century. Early European contacts brought a panoply of
new viral diseases: influenza to Tahiti in 1772 and Fiji in 1791, smallpox to Guam
as early as 1688. Tuberculosis followed Europeans to Fiji by 1791, dysentery to
Tahiti in 1792, syphilis to Tahiti in 1769 and to Hawaii in 1779. But more frequent
contacts in the nineteenth century combined with significant movements of
laboring populations to intensify disease diffusion. In the 1860s Polynesian labor-
ers returned home from work in Peruvian mines, bringing a new wave of small-
pox with them. Chinese and Melanesian laborers carried leprosy to Hawaii in
the 1830s, to New Zealand in the 1850s, and to New Guinea in 1875. In the same
year a serious measles epidemic devastated Fiji, and measles spread to Vanuatu
and the Solomon Islands as well. Still another pattern of migrant labor brought
disease to Fiji in 1879, when Indian laborers carried a fresh smallpox epidemic
as well as cholera. The Caroline Islands were struck by influenza, smallpox, and
186 The Burdens of Disease

whooping cough; the Marshalls by influenza, syphilis, and dysentery, some of it

brought by Chinese laborers; measles, influenza, and whooping cough all
reached the Cook Islands.16
In addition to transporting infected humans and their microorganisms,
steamships could also be efficient carriers of disease vectors. Thus a serious
malaria epidemic struck Mauritius in 1866, after Anopheles mosquitoes arrived
there by ship; similarly Anopheles gambiae, not native to Brazil, made its way
there by sea, reaching the city of Natal in 1930.17
Nineteenth-century transportation also brought together different subpopula-
tions within a single country, and changed the biological environment as it did
so. The previously isolated island populations of the Philippines began converg-
ing in cities and traveling from island to island, and separate disease environ-
ments broke down there. The network of railways built by British capital in India
greatly magnified the problems associated with the subcontinent’s already for-
midable traffic in pilgrims. Cholera, smallpox, tuberculosis, malaria, dysentery,
and diarrhea followed them around, and pilgrim traffic may also have contributed
to the rapid and catastrophic diffusion of plague in the years after 1896.
Western penetration also meant ecological changes. Plantation agriculture
could have immediate effects on a disease environment. For example, in Egypt
the demand for raw cotton encouraged the country’s westernizing ruler
Muhammed Ali to introduce “perennial irrigation” north of Cairo, and later
British influence and investment finished that job by cleaning irrigation canals
and building the Aswan Dam. The result was a nearly ideal environment for
bilharzia, a parasitic disease carried by snails.18 As British and Afrikaner settlers
pressed toward the Limpopo river valley in South Africa, their firearms reduced
the game population, reducing in turn the Anopheles mosquitoes and tsetse flies
that had made the valley a center of malaria and trypanosomiasis (sleeping
sickness).19 Other ecological changes showed the complex interrelation of
human and animal diseases; when rinderpest found its way into the Philippine
cattle population in the late 1880s, the decline in cattle led mosquitoes to turn to
secondary hosts—humans—and an increase in malaria followed.20 Political
change too could have ecological and hence disease consequences. Belgian rule
in Congo redrew territorial boundaries and with them traditional agricultural
arrangements that had limited the contact of humans and the tsetse fly. When
the traditional patterns of cultivation broke down the incidence of African
trypanosomiasis rose.21
But the most complicated and far-reaching effects of Western imperialism on
disease environments stemmed from the social and economic changes that
accompanied Western control. In the wake of Western domination came
enlarged urban populations, difficult working conditions, increased population
mobility, and many of the stresses of modernization. At the same time existing
Disease, Medicine, and Western Imperialism 187

social structures and values were systematically discounted or dismantled, and

with them much of the traditional routines of healing.
Urbanization created new foci of disease in many parts of the Western impe-
rial world. In Southern Rhodesia (Zimbabwe), cities, mining compounds, and
mission schools all became important centers of influenza, and the movement of
labor to “pass offices” (where identities were checked) was a mechanism for
influenza’s transmission.22 In Indochina the growth of urban areas under French
rule was accompanied by spreading Western viral diseases and tuberculosis.23
In South Africa, where Westernization was relatively complete, a full comple-
ment of Western urban health problems combined with the massive social dis-
ruption of “conquest.” The great mineral discoveries in that country—diamonds
in the late 1860s and gold in the 1880s—led to dramatic concentrations of peo-
ple, heavy labor at great hazard in mines, and impoverishment of much of the
countryside as labor was pulled off the land. The resultant poverty opened the
door for epidemics that continued into the twentieth century. The health prob-
lems of a mining culture spread far over the globe: the terrible working condi-
tions of the phosphate mines of Nauru led to beriberi, influenza, typhus, and
dysentery, and the riches of the mines led to the eventual high per capita income
of independent Nauru and the problems of obesity and hypertension that accom-
pany it.24
Social and economic change led of course to migrations as well, some of
which I have already noted. In Congo labor-intensive exploitation of ivory and
rubber took men out of primary food production as well as uprooting people from
their homelands, although Maryinez Lyons discounts the importance of the lat-
ter factor in the region’s disease history.25 The growing demand for sugar in
Zululand encouraged the migration of Indian labor to that South African terri-
tory, and this in turn fueled a malaria epidemic in the 1920s. All through East
and Central Africa in the late nineteenth century the movement of people work-
ing as porters and bearers for the conquering European armies disrupted local
health systems and spread new diseases.26
Simple “modernization” often had unforeseen disease consequences. The
construction of dams for irrigation and electric power in Africa created condi-
tions for the spread of schistosomiasis, while the extension of cash crops into
the Tanzanian economy made demands on female labor that in turn increased
perinatal mortality.27 In India irrigation and road building created ideal environ-
ments for Anopheles mosquitoes and hence for malaria. In the Philippines the
conversion of land to cash crops forced the population to rely on imported—and
milled—rice from Indochina and Siam, rice lacking the vitamin-bearing husks
that guarded its consumers from beriberi.28
Intellectual and cultural pressures accompanied these tremendous effects on
the environment. Western medicine contradicted, and/or rode roughshod over,
188 The Burdens of Disease

other healing systems. The spread of smallpox vaccination illustrates that phe-
nomenon. Such vaccination met widespread resistance, often on grounds similar
to those found in European societies themselves. Many Indians believed that
smallpox was caused by goddesses, and so religious remedies were needed; local
practices of variolation offered another alternative to vaccination. Sub-Saharan
Africa likewise had traditional variolation methods that opposed colonial vaccina-
tion. And in French North Africa (especially in the years before 1860) vaccina-
tion was seen by Muslims as a “threat to cultural integrity” and as a scarification
with ritual (and alien) significance.29 In some cases vaccination simply made
very slow progress, owing not only to such cultural conflict but also to internal
weaknesses in colonial administration.
Western rule also meant attempts at establishing a sanitary regime whose fea-
tures might conflict with a myriad of other beliefs, both Western and non-
Western. Attacks on rats might be resisted by Hindus in India, despite the
conviction growing after 1900 that the animals played an important role in plague
transmission. North Africans perceived French sanitationism as saying that all
the Arab world was dirty and inferior, and they widely resented and resisted it.
The American acquisition of the Philippines in 1898 preceded a public health
“campaign” for which military metaphors seem if anything understated. And
everywhere the march of Westernization and modernization put inevitable indi-
rect pressure on traditional healing modes. Urbanization might—as it did in
Africa and Oceania—take males in particular out of the reach of traditional vil-
lage healers as the migration of labor to mines and distant plantations proceeded.
Miners in Rhodesia found themselves transplanted away from the protection (or
revenge) of their territorial gods.
Western ideas themselves did not always wholeheartedly support either sani-
tationism or biomedicine in the colonies. No doubt the enormous pilgrim traffic
of India posed serious threats for public health, and no doubt the railway sped
and magnified that traffic. But should that traffic be controlled? The idea of a
bureaucracy to control traffic conflicted with some of the most deeply held beliefs
of the British rulers; a thalassocracy benefited from facilitating the movement of
people, not hindering it. Health policy may have been a tool of empire, but it was
often underfinanced; colonial regimes were often loath to spend money.

Illustrative Examples
Western “imperialism” is a slippery topic for generalizations, and so too
are its consequences for disease. Many different variables came into play:
topography, climate, the disease environment before Western domination, the
length of time between first contacts with the West and domination by it, and
(most diverse of all) the nature of the West’s social and economic impact.
The four examples that follow illustrate different themes and hence suggest
Disease, Medicine, and Western Imperialism 189

something of the complexity that must attend any answer to the question: how
did Western imperialism affect the rest of the world’s disease history?

The Fiji Islands afford a clear example of the workings of a well-
documented “virgin soil” epidemic, an onslaught of measles in 1875.30 The first
European to see the Fiji Islands, Abel Tasman, did so in 1643; William Bligh, cut
adrift in a launch by the Bounty’s mutineers in 1789, sailed through the islands
and returned in 1792 to chart many of them. By that date epidemics had proba-
bly begun attacking the Fijian people. Population estimates vary widely for the
period before the assumption of British rule in 1874, but early estimators talked
both of declining numbers between 1800 and 1870 and of epidemics. An epidemic
of 1791–92 may have been pulmonary of some sort, perhaps tuberculosis; acute
dysentery struck in 1802–1803, with perhaps even more serious effects than the
measles disaster of 1875; an influenza epidemic occurred in 1839.
Unclear documentation clouds the relation of these disease episodes to con-
tacts with Western peoples. Certainly such contacts intensified as Western
traders arrived to exploit first the sandalwood of Vanua Levu and then the
trepang found in the surrounding waters. Christian missionaries followed
closely; by about 1850 Wesleyan Methodists, the most active and successful, had
established their circuits over most of the Fiji Islands. By the middle of the
nineteenth century this Western presence had contributed to political and eco-
nomic upheaval in the islands; intermittent wars between local chiefs punctuated
the introduction of plantation agriculture by Western entrepreneurs (cotton in
the 1860s, then sugar). The plantation owners began importing indentured labor,
first Melanesians from Vanuatu and the Solomons, then Indians. When Great
Britain assumed sovereignty over Fiji in 1874, therefore, the islands had already
experienced both an intensified human contact with distant places and peoples
and considerable changes in their traditional economy and society.
But Fiji had apparently not experienced measles until January 1875, when
HMS Dido arrived at Levuka, then the capital of the principal Fijian chief,
Cakobau. Cakobau himself, and his sons, were returning on the ship from a state
visit to Sydney; there Cakobau had contracted a case of measles, and his sons
became infected on the return voyage. An ideal situation for the diffusion of an
epidemic awaited them. Despite the illness on board, no quarantine greeted the
vessel. For ten days after the Dido arrived, Cakobau entertained subordinate
chiefs, explaining the arrangements that he had made for the cession of Fijian
sovereignty to Great Britain; eventually eight hundred Fijian dignitaries met
Cakobau, then returned to their homes. As Andrew Cliff and Peter Haggett note,
“it is hard to imagine a diffusion hierarchy more calculated to accelerate spread
of the virus,” and spread the virus did. It was a situation involving an “unusual
190 The Burdens of Disease

number of people who have come long distances, who meet in loose concourse,
who then return to all parts of Fiji where they are met in their turn by local
groups.” Measles, together with the political news, “spread hand-in-hand down-
ward through the layers of the social hierarchy.”31 By the middle of February
measles had spread over most of the Fiji Islands, with the peak of the epidemic
wave moving from Ovalau and Bau (where the Dido made its first contacts) in
March to the rest of the chain in April. The epidemic ended by early June 1875,
except for some continuing cases in far-outlying islands.
In those few months Fijian society came to a nearly complete halt. Estimates
of total deaths have ranged from 27,000 to 50,000, out of a population estimated
at 135,000; Cliff and Haggett, combining that population estimate with the
“official” mortality rate of 27 percent, suggest that 36,000 deaths may be a rea-
sonable figure.32 The magnitude of the human disaster was felt as far away as
London, where Lord Carnarvon, the colonial secretary, told the House of Lords
that “a very large proportion indeed of the population have perished,” and mused
on the fact that “diseases which have, comparatively speaking, little effect upon
civilized populations produce most disastrous results in the case of Native races,
and just in proportion as the race is remote and isolated so are the ravages of the
disease violent.”33 As had happened in similar catastrophes elsewhere, the epi-
demic’s scale magnified its severity, as society ceased to be able to care for the
sick. An 1893 British report recalled that in 1875 “whole communities were
stricken at one time, and there was no one left to gather food or carry water, to
attend to the necessary wants of their fellows, or even, in many cases, to bury the
dead”; the same report spoke of the “apathy and despair” of the people. To relieve
their fever some Fijians lay in water, or exposed themselves while wet to cooling
Subsequent measles epidemics in Fiji illustrate both the diminishing effects
of a disease in what had ceased to be virgin soil and the clear importance of steam
transportation in disease diffusion. The next serious measles visitation was in
1903 and resulted in about 2,000 deaths; in 1910–1914 another attack killed 344,
but deaths from subsequent measles epidemics were very few, although large
numbers of cases often resulted. The disease had been domesticated as a rela-
tively mild (and largely childhood) complaint. Those most affected might have
been (as in 1936–37) Polynesian migrant workers from Tonga and the Gilbert
and Ellice Islands, who lacked the immunities that Fijians had developed.
Cliff and Haggett have clearly shown the impact of steam navigation on the
later conveyance of measles to Fiji. Measles is a highly contagious viral infection
that passes directly from person to person. Its victims are infectious for nine days
after the onset of symptoms; symptoms manifest themselves after a latent period
of eight to twelve days. These epidemiological facts show that the shortest chain
of transmission (from the onset of one case to the onset of the next) is eight days,
Disease, Medicine, and Western Imperialism 191

made possible when a victim makes contact with another when symptoms first
appear and the new victim’s infection appears after the minimum latent period
eight days later. The longest chain of transmission is twenty-one days, accom-
plished when the initial victim makes contact in the last, ninth, day of his infec-
tivity and the disease lies latent in his contact for twelve further days. The
average chain of transmission, Cliff and Haggett suggest, is fourteen days.
India was a continuing source of measles for Fiji, for between the subconti-
nent and the islands a regular stream of migrant labor flowed in the late nine-
teenth century. Between 1879 and 1916 eighty-seven voyages carried 61,000
laborers from India to Fiji. Sailing ships dominated the early years of this traffic.
To reach Fiji from India they sailed to the south of Australia, catching the favor-
able winds of the “roaring forties.” The resulting voyages took an average of
seventy days, at times as many as ninety, or time for five or six measles “genera-
tions” to move through the ship’s company. This immigrant traffic was carefully
monitored, for a surgeon accompanied each ship and noted the voyage’s disease
history. No sailing ship from India reached Fiji with measles; although a number
left India with cases, the disease always exhausted the available susceptibles in
the course of the long voyage. But steamers traveled between India and Fiji much
more quickly, in part because they could steam directly through the Torres
Straits to the north of Australia. An average steamer trip was thirty days, not sev-
enty, two or at most three “generations” of measles. Steamers carried more pas-
sengers, which increased the list of potential susceptibles. And the records of
ships’ surgeons show that steamers, unlike sailing ships, did reach Fiji with
active measles cases in the years after 1884 when the use of steamships began
for such voyages. As it turned out the effect of steamship-conveyed measles from
India was not great, for when the ships arrived they were quarantined (a process
that began to be enforced after the 1875 epidemic), and most of the infected
Indian immigrants would join a community of compatriots who had already been
exposed to measles. But the power of steamships as diffusers of disease can be
precisely demonstrated by the example.35

The Philippines
Although Fiji’s 1875 experience with measles coincided with a rising
level of Western power and influence, its disease environment remained rela-
tively uncomplicated by Western impositions of social change, political control,
or biomedical intervention. The experiences of the Philippines in 1899–1902 were
quite different, for there outbreaks of three of the classic epidemic diseases
(plague, cholera, and smallpox) accompanied a war in which the United States—
a new Western ruler—was imposing its will on the Philippines. A dramatic illus-
tration of the full panoply of an interventionist state, mobilized in the name of
conquest (whether of human or microbial enemies) resulted.36
192 The Burdens of Disease

The Philippine Islands had a long history of contacts with the West as well as
with the civilizations of mainland East Asia. Spain asserted a theoretical claim
early in the sixteenth century, and by 1571 the Spaniards had founded the settle-
ment of Manila on Luzon. From that time until the late eighteenth century Spain
basically regarded the Philippines as the “mere raft for barter, silver against silk,”
its intermediary between the silks of China and the silver of Mexico.37 In those
years, therefore, Philippine society was relatively little affected by the Spanish
presence at Manila, although its position as an entrepôt made it part of a wider
disease world. But in the late eighteenth century Spain began to diversify its eco-
nomic uses of the Philippines, and in the next hundred years the islands were
enmeshed in a more complex system of international trade as Spanish interests
developed Philippine plantation agriculture: sugar, tobacco, hemp, and indigo.
Ken DeBevoise has argued that the health of Filipinos suffered, as cash crops
replaced subsistence and garden agriculture and the local diet declined to rice,
sugar, fish, and little else. Further, an increasing proportion of the Filipinos
ceased being smallholders, becoming first tenants and then landless migrant
laborers, bandits, domestic servants, or prostitutes; the gulf widened between
the successful few and the unfortunate many.
By the late nineteenth century the population of the Philippines may have
been particularly susceptible to the ravages of epidemic disease. In the summer
of 1896 an insurrection against Spanish rule began, led by Emilio Aguinaldo. The
Spanish government managed to dampen that fire, if not extinguish it, by late
1897, only to be led into a war with the United States in the spring of 1898. That
“splendid little war” was brief, and the Americans wound up in possession of the
Philippines as well as other pieces of Spanish imperial territory. During the war’s
course Aguinaldo proclaimed Philippine independence; when Spain ceded the
islands to the United States in December 1898 he and his followers refused to
accept the transfer of their yoke from one Western master to another. A rebel-
lion against American rule in early 1899 continued until at least early 1901 (when
Aguinaldo was first captured and then swore allegiance to the American regime)
or perhaps early 1902 (when the fighting actually ceased). In the midst of this
insurrection plague appeared in the Philippines, part of the epidemic that began
spreading from China in 1894, and as plague waned a cholera epidemic began in
March 1902. And all the while both Spanish and American rulers also wrestled
with smallpox, which enjoyed a surge in the turmoil of war.
The 1902 Philippine cholera epidemic was especially severe, although it was
hardly the first to reach the islands. It arrived from Hong Kong or Canton, per-
haps accompanying a trade in vegetables from those Chinese ports. The result-
ant Philippine death toll has been estimated by Rodney Sullivan at over 200,000,
although Reynaldo Ileto opts for a more conservative 109,000. Those two
Disease, Medicine, and Western Imperialism 193

students agree on much else, however, especially on the vigor of the American
“military” response to this epidemic, seen by Ileto as a “chapter in the Philippine-
American War” and by Sullivan as part of a more general attempt to
“Americanize” the Philippines.38 Cholera stimulated American fear of Philippine
“filth,” and the American government determined to impose American standards
of sanitation and cleanly civic behavior on the islands. In the short run quaran-
tines and isolations were imposed, in which military authority could and did over-
ride traditional commercial objections to quarantines, traditional resentment at
the burning of the houses and other property of the sick, and traditional social
taboos against cremation. The gospel of sanitation was preached, sometimes
with considerable condescension:

Do not despair
. . . The only remedy that’s sure
Is, after all, the water cure;
Don’t shoot ’em,
Loot ’em,
Cuff and boot ’em,
But lead ’em firmly to the tub
And make ’em scrub.
Despite their howls
And growls;
Teach ’em the use of soap and towels.
For cleanliness once understood,
Creates a higher brotherhood,
It makes men willing to be good;
. . . Remember, while there’s soap
There’s hope.39

The results were ambiguous. The Americans had, they believed, waged a
successful campaign against the onset of plague in 1899, and they could also
glory in their striking success against malaria and yellow fever in Cuba (to be
discussed later in this chapter). But the military assault on cholera in the
Philippines disrupted harvests and thus weakened Philippine diets, while the
concentration of people in camps created favorable conditions for the spread of
malaria and dysentery. Both Sullivan and Ileto argue that the American struggle
with cholera paralleled earlier Spanish efforts in both its intentions and in its
results. Both the Spanish (in the cholera epidemic of 1882) and the Americans
(in 1902) intended “to consolidate their colonial state, to suppress forms of disor-
der and irrationality, and institute modes of mass surveillance.”40 And the possi-
bility remains that neither the Spanish nor the American measures affected the
194 The Burdens of Disease

course of cholera very much. Both epidemics, 1882 and 1902, ran similar courses,
despite the apparently much more successful (or at least active) American
assaults in the latter year. Did cholera burn itself out without regard for human
The American attack on smallpox was a clearer success. Smallpox had long
bedeviled the Philippines, and the Spanish government had mounted serious
vaccination campaigns against it. The Spanish encountered the general prob-
lems that disrupted many Western attempts to extend vaccination to colonial
possessions, or indeed to their home populations. Governments often lacked
effective means of compulsion, and even where such legal means existed colo-
nial governments (especially) often lacked the money to mount an effective
vaccination campaign. They too frequently employed underpaid or unpaid vacci-
nators, who were typically poorly trained and poorly motivated. Vaccines used in
colonial medicine were too often attenuated, inert, or contaminated by bacteria,
so that they either conferred inadequate immunity from smallpox or actively
spread other diseases. Vaccination as a response to smallpox often countered
traditional beliefs about the disease’s cause; many Filipinos, for example, saw
spirits as responsible for smallpox and believed that appeal to them was more in
order. Others positively feared vaccination. Was vaccination simply dangerous
to health? Did it usurp the activities of local healers?
For all these reasons the Spanish efforts to vaccinate the Philippine popula-
tion remained incomplete, and smallpox persisted in the islands. American
efforts were more successful, perhaps in part because the new rulers were ini-
tially stimulated by the urgency of a war and employed the power of military gov-
ernment. As DeBevoise reconstructs the situation, an unusual proportion of
American troops may have arrived in the Philippines with strains of smallpox
(especially Variola minor), and the disruptions of war increased opportunities
for contagion.41 The continuing hostilities, from 1898 to 1902, gave rise to flight
by many fearful civilians, regional overcrowding, and the inevitable widespread
fraternization between American troops and Filipinos, all of which contributed to
an ideal epidemic situation. The American authorities, fearing first for the health
of their troops (another common colonial issue), began a massive vaccination of
the civil population, and it met surprisingly little resistance. Perhaps after
decades of Spanish efforts vaccination was more familiar; perhaps, as DeBevoise
speculates, its administration contrasted with the harsher anticholera measures
and so was less resented. Ileto notices that the resistance stimulated by the anti-
cholera measures led American authorities to make some accommodation to
Philippine customs and folk healers. And the Americans simply had more
resources than the Spaniards had had. So although a serious smallpox epidemic
flared in the Philippines in 1918–19, by 1929–30 endemic smallpox had disap-
peared from that country, the first place in Asia to achieve that goal.
Disease, Medicine, and Western Imperialism 195

The “Crown Jewel” of the British Empire, India occupied an unusual (if
not unique) position on the European world horizon.42 By the early nineteenth
century Britain had gradually gained control of a subcontinent that contained
some of the oldest, most populous and complex, and richest civilizations in the
world. In this conquest the possibility of eradication of the indigenes and their
replacement by European settlers could never remotely arise; European
migrants could never be more than foam on the surface of oceanic Indian soci-
ety. Within the subcontinent a vast panoply of traditions and languages coex-
isted, maintained by peoples who had rarely been politically united and then
usually by the yoke of one “foreigner” or another, of whom the British were the
latest and most effective. British rule, therefore, had to make its way through a
dense thicket of local beliefs and customs. It also confronted two great religions,
Hinduism and Islam, and a number of others with substantial followings as well.
Western cultural influence spread only gradually and incompletely in this
“conquered” territory. Although the British imprint was ultimately very deep,
the cultures of India were not thrust easily aside. Indigenous elites retained con-
siderable power; in some regions of India they retained at least titular political
control. The economic impact of the West took a somewhat unusual form as well.
Many other imperial places simply saw their economies overwhelmed by the
West, which converted their lands to plantations and exploited their mineral and
human resources. India was certainly “exploited” by the British, but the imposi-
tion of new products and the breakdown of economic structures proceeded much
more gradually, and the whole land of India never became a plantation for the
production of export cash crops. In part because India assumed an unusual
importance in British imperial thinking and policy, economic change included a
significant measure of capital infrastructure, itself another contributor both to
gradual economic changes in India and to effects on the disease environment.
That environment clearly differed from that of isolated Pacific islands such as
the Fijis, of outlying archipelagos such as the Philippines, or of thinly settled
continental expanses such as much of North America. Many diseases had been
at “home” for many centuries in India, where their causative organisms flour-
ished in the warm moist climate and where they could feed on (and interchange
among) the numerous humans and their even more numerous livestock, espe-
cially cattle. India was obviously not “virgin soil” for European diseases; more
often it played the role of exporter, not importer, and Europeans certainly per-
ceived it as a dangerous disease environment. Those perceptions themselves
affected imperial disease history. And the complexity of Indian society meant
that the relations of the British rulers with indigenes filtered through a number
of levels: the British government of India itself enjoyed a varying measure of
freedom of action from the dictates of Westminster, while within India that
196 The Burdens of Disease

government faced different local elites which might themselves be at cross-

purposes, or might be at absolute loggerheads with more humble elements of
society. All this meant that in India huge gulfs might yawn between imperial
policy (about some disease issues, for instance) and what actually happened in
the country. India superbly illustrates what Mark Harrison calls the “limited
scope and effectiveness” of imperial disease policies.43 That the control of health
and disease became a “tool of empire” has become something of a historical
cliché; India tests the limits of that cliché very severely.

Cholera. The imperial government’s confrontations with cholera, a disease

long “native” to India, illustrate both the complexities of imperial health policy
and the interrelation of disease with the evolving Indian society. In the
eighteenth century the British had generally shown some respect for Indian
traditions and ways of life, including Indian approaches to disease and health.
Enlightenment notions of disease that emphasized the importance of environ-
ment were applied by Europeans to India, with the result that Indian conditions
were held responsible for Indian diseases such as cholera; Indian remedies
might also therefore be better informed. This environmentalist view persisted
long into the nineteenth century, although British respect for Indian traditions
did not. British evangelical Christians and British utilitarians agreed (especially
from the 1830s on) that India’s customs should be rationalized and civilized, that
is to say Westernized. Much of the enthusiasm for making India into a Greater
Britain diminished after the Sepoy Rebellion of 1857; its events, many of them
weighted with symbolism that affected Britons and Indians very differently but
equally deeply, convinced many British that India was beyond redemption and
that British rule could aim only at lofty trusteeship of the unregenerate barbar-
ians. The 1857 rebellion had other effects as well: it made British authorities very
leery of provoking a reprise, and it made them determined to safeguard the
health of their troops, their front line against another Kanpur massacre.
Attempts to better the health of the British troops in India reflected both the
enthusiasm for sanitation of the 1860s and the Anglo-Indian conviction that
Indian diseases were the products of Indian environments. Cholera was a dis-
ease of “locality.” Army cantonments and “civil lines” were carefully sited, condi-
tions of barracks were modified, drainage and water supply received attention,
reforms of nutrition and drinking habits were pursued. Some of these measures
involved an increasing segregation of the Indian and European populations, for
1857 had helped convince the British that proximity to Indians might be both
biologically and politically dangerous.
British, and especially British Indian, thinkers about cholera resisted ideas
that were gaining acceptance in European thought by the 1860s and 1870s. When
a cholera epidemic began in 1867 in the northwestern city of Hardwar, where
Disease, Medicine, and Western Imperialism 197

pilgrims had gathered, the different theories came into conflict. In the previous
year an international conference on cholera had called India the “natural home”
of the disease, and European delegates had urged that the Indian government
impose quarantines and controls on the movements of pilgrims, both within India
and from India to other places.44 And indeed the 1867 epidemic seemed to follow
the Hardwar pilgrims home, lending credence to the conference’s view. But the
government of India hesitated to offend religious pilgrims by interference in their
freedom of movement, partly because it feared provoking Indian resistance and
partly because mid-nineteenth-century British governments tended to favor free-
dom of movement and trade anyway. And in any case the Indian Medical Service
(IMS) as a whole remained unconvinced that contagionism explained cholera; it
was a disease of locality, carried through the air.
The 1867 cholera epidemic hinted at a problem that would magnify in the remain-
der of the century: that the diffusion of disease throughout India would be greatly
facilitated by the improvements in infrastructure and modernization of the econ-
omy that British rule (and British investment) brought, especially in the decades
after 1857. Pilgrimages had always carried serious disease possibilities, for they
brought together large crowds in small spaces, crowds that then dispersed to their
home villages. Railroads in India—288 miles of them in 1857, 24,760 miles in
190045—increased the number of pilgrims and the distances they could travel, and
created their own noxious disease environments, crowded, dirty, without ventila-
tion or water. In 1927 third-class waiting rooms were still called “universal sources
of malarial infection.”46 Railroad construction brought large labor forces together
and moved them around the country; railroads were built on embankments (to pro-
tect them from flooding) that in turn disrupted natural drainage patterns. Railroads
were an important element (though not alone) in increased population mobility and
agglomeration, which changed the disease environment of India.
Subsequent cholera epidemics might move very rapidly, but official responses
to them replayed the themes of 1867. Renewed cholera in the 1880s led to
renewed international calls for quarantines, especially from France (fearful of dis-
ease reaching its shores through the Mediterranean) and Turkey (in whose terri-
tory the great magnets for Muslim pilgrimage were located). But interfering with
the travel of Indian Muslims to Mecca seemed politically dangerous to the British
rulers, and Indian business interests (especially the merchant community of
Bombay) also resisted quarantines. Hoping to appease international criticism, the
Indian government created a medical board for Bombay and proposed more thor-
ough regulation of allowable space for passengers on pilgrim ships. The medical
board was to report “whether the trifling cholera usually to be found [in Bombay]
had assumed an epidemic form,” and so Bombay joined the long list of cities that
found euphemisms for epidemics.47 The prospect of closer regulation of pilgrim
ships divided the Muslim community, for the prosperous classes supported a
198 The Burdens of Disease

move that would thin out the noisome hoi polloi, while the poorer elements
decried the higher fares that would bar them from fulfillment of religious obliga-
tion. In all this controversy the British government found itself hamstrung:
between the pressure of France and Turkey on the one hand and the desires of its
own Indian government on the other; between some groups of Indians (who
demanded more public health action by government) and others (for whom pub-
lic health action contradicted religious, cultural, or economic values).
The Indian Medical Service, holding to its environmentalist and holistic con-
ception of cholera, also resisted both Snow’s theory of cholera as a waterborne
disease and Koch’s arguments about its bacteriological cause. Many Indian doc-
tors found an ally in the great German sanitationist Max von Pettenkofer. And a
pure water supply was not an obvious answer. In Calcutta a piped-in water supply
was completed in 1869, part of the sanitary enthusiasm to protect the European
population that so characterized the 1860s. Death rates in the city indeed
declined in the next several years, but the new volume of fresh water soon over-
whelmed the city’s inadequate drainage system and death rates rose again. By
the 1870s the Indian government had entered into a new phase marked by both
economy and a desire to create institutions of local self-government for Indians,
and neither the central Indian government nor the newly formed municipal gov-
ernments wanted to spend money on such expensive projects as sewers and
storm drainage. Municipal governments, dependent on the votes of local prop-
erty owners and taxpayers, resisted raising the necessary taxation. And Bombay
medical authorities created their first medical laboratory in 1884 explicitly to
refute Koch’s bacteriological arguments. But by the 1890s Koch’s beliefs had
made headway even among members of the Indian Medical Service, perhaps
because if cholera was really the product of a bacterium then the disruption of a
quarantine was unnecessary.
The reluctance of British doctors in India to accept newer currents of thought
about cholera may have stemmed from more general weaknesses in their social
position, which among Anglo-Indians was not particularly high. Members of the
Indian Medical Service occupied less prestigious social rank than military offi-
cers and members of the civil service. Partly for that reason, but also owing to
the extreme climate, the low scale of rewards, and the slowness of promotion
within the service, the IMS had difficulty recruiting able physicians from British
schools. In that situation, Mark Harrison reasonably argues, many Anglo-Indian
doctors responded conservatively to the challenge of new ideas, especially when
those ideas threatened not only their long-held beliefs but also the economic
prosperity and political stability of the state they served.48

Plague. Plague, unlike cholera, was not a “domestic” Indian disease. It arrived
in Bombay in August or September 1896, probably from Hong Kong. A brief
Disease, Medicine, and Western Imperialism 199

period of denial ensued, perhaps furthered by the fact that the first diagnosis
came from an Indian physician whose competence the British doubted. But
European states insisted that the menace be faced. An international conference
in Venice criticized the government of India for its laxness about plague (as ear-
lier meetings had complained in times of cholera), and quarantines against
Indian goods were imposed. Stung by this international action (and perhaps, as
Rajnarayan Chandavarkar has argued, driven by panic) the British Indian gov-
ernment responded vigorously, especially in afflicted Bombay.49 A determined
search for plague victims began, with mandated house searches. Sufferers were
isolated and their families segregated; goods and houses were subject to disin-
fection or destruction by fire. Working on the theory that plague was somehow
conveyed through earthen floors, authorities dug up and disinfected such floors,
an especially expensive and time-consuming response, and one that (as Charles
Gregg remarks) simply dispersed rats more quickly.50 Controls on rail travel
resulted in much interference with traffic and some degrading physical examina-
tions of passengers. Internal Indian quarantines were proclaimed on goods and
people moving from Bombay.
These measures stirred considerable resistance, and by 1898 such aggressive
steps had been softened, even though for some their theoretical justifications
remained. The government responded to local pressures, coopting local leaders
and indigenous health practitioners into its efforts, making more effort to respect
the purdah privacy of women and the sensitivity of Hindus previously taken to
hospitals in which castes were mingled. In addition to their greater sensitivity,
perhaps (as so often) driven by a fear of provoking another 1857, Indian govern-
ments lacked the money to implement a comprehensive public health police
state. The international pressures for quarantine eased as well. By 1900 two
newer approaches received more attention: the application of a preventive
vaccine and the attack on the rat as a likely plague vector.
A plague vaccine was the product of Waldemar Haffkine, who had also devel-
oped a cholera vaccine. Haffkine, a native of the Russian Empire, began experi-
ments with a plague vaccine in 1897, three years after the apparent causative
organism of the disease had been isolated by Shibasaburo Kitasato and
Alexandre Yersin. I. J. Catanach suggests that established practitioners in Indian
medicine were slow to respond to Haffkine’s work, in part because they resented
him as an outsider; but by 1901 a considerable population, especially in the
Punjab, was receiving Haffkine’s plague inoculation. At about the same time the
possibility that rats carried the disease won some favor (although P. L. Simond’s
1898 experiments had to be repeated in Australia and India before Indian physi-
cians were convinced). Vigorous campaigns to kill rats commenced, but these
were unrealistic and were modified by 1908 to control the access enjoyed by
rats to human dwellings. Catanach argues that by that date a kind of apathy had
200 The Burdens of Disease

overtaken the antiplague effort in India, an apathy borne partly of racist compla-
cency; the disease, though it ultimately killed twelve million Indians, was not
spreading as the new Black Death to the West.51
This appearance of plague in India generated much social and philosophical
conflict. The aggressive sanitation responses of 1897 especially stirred opposi-
tion. Textile mill owners objected to the steam-sterilization of their goods, a pro-
cedure that they said weakened fabrics. Indians feared isolation hospitals, and
fled to avoid them. At least initially, patients in isolation hospitals shared wards
regardless of caste, a mixing deeply offensive to some Hindus. The abandon-
ment of infected property meant its almost certain loss, perhaps to thieves, and
so owners resisted demands for its surrender. More generally, merchants resis-
ted quarantines, which deeply crippled their export trades; Calcutta was espe-
cially hurt by the European embargo on Indian hides and skins, exports
particularly shipped from that city. The quarantine seemed especially unjust
because Calcutta had no confirmed plague until 1898, and even after that
remained relatively lightly affected. Bombay suffered from the plague itself, from
the flight of 100,000 of its inhabitants, and from the quarantines imposed by other
Indian cities on trade with the city. Railroad companies resisted attempts to
control rail traffic in the name of public health; such efforts seemed both inter-
ference with free trade and discrimination against some travelers. Muslims
opposed restrictions, insisted upon by the Turkish government, on pilgrim traf-
fic from Bombay to Arabia. The Indian government, hoping to please both Turks
and its own Muslims, suggested that Bombay Muslims sail from Madras or
Karachi instead, but that plan stirred the ire of Karachi and especially Madras,
whose Hindu citizens did not want pestilential Muslims moving through
their midst.
All these different conflicts (coinciding as they did with periods of poor har-
vests) led to general and serious social unrest, especially in 1897. A major riot
occurred in Calcutta in June of that year, and an Indian Civil Service officer was
assassinated in Poona. The mere suspicion that aggressive antiplague measures
were to be enforced in Calcutta resulted in 150,000 fleeing that city in 1898.
The new emphases of the years after 1900 also stimulated social controversy.
Campaigns against rats encountered the ire of devout Hindus, some of whom
sabotaged rat traps. Haffkine’s vaccination efforts met opposition both from those
who favored a heavy state hand for sanitation and from those who felt that the
Russian Jew was socially—if not politically—suspect. Much popular sentiment
resisted vaccination as well. Although not all Indians set themselves against the
vaccine (and Radhika Ramasubban has even argued that leading elements of
indigenous Indian opinion were quicker to support vaccination than were British
authorities),52 as early as 1898 rumors circulated through Calcutta that Haffkine’s
vaccine was in fact a poison prepared by the government; another report claimed
Disease, Medicine, and Western Imperialism 201

that the vaccine had been prepared in the flesh of pigs and cattle, the same
explosive mixture that had ignited the 1857 rebellion by inspiring both the dis-
gust of Muslims and the devotion of Hindus. And when, in the middle of the mas-
sive inoculation of about 500,000 Punjabis in 1901–1902, nineteen subjects died
of tetanus, anti-Haffkine and antivaccination opinion seized the moment. The
government, right up through the viceroy, Lord Curzon, laid the blame on
The conflicts within indigenous Indian groups, and between those groups and
the British-led government, therefore often limited public responses to disease
emergencies. They also confirmed British critics in their view that India was
uncivilized and incapable of self-government, while the persistence of disease in
cities joined political fears to make places such as Calcutta the “focus of deep-
seated European anxieties.”54

South Africa
The disease history of South Africa in the nineteenth and early twenti-
eth centuries illustrates additional interactions between the expansive European
world and other societies.55 At the start of the nineteenth century South Africa
already had a European population (estimated at about 42,000 in 1819), and as
the century went on further migration augmented the European numbers, espe-
cially after about 1870 (at which point the Europeans might have numbered
about 250,000).56 The original European settlers, the Afrikaners—an amalgam
of French Huguenots and Dutch—had begun creating a pastoral society in the
seventeenth century, one whose produce replenished ships calling at the Cape
of Good Hope on their transits between Europe and Asia. This initial arrival of
Europeans displaced some indigenous Africans; here as in the Americas small-
pox played a role, greatly diminishing the number of the indigenous Khoikhoi in
the Cape area.57 As the Afrikaner population grew so too did the area it con-
trolled, for many Afrikaners had little interest in staying close to the seaports
and instead preferred an isolated self-sufficiency that drew them further inland.
The British seizure of the Cape (first in 1795, then confirmed in 1815) acceler-
ated that Afrikaner movement, as the “Volk” escaped the restrictions and differ-
ent society of the British. British settlers themselves began arriving in the 1820s.
The British and their settlers regarded the Cape as of great strategic importance,
supplying and protecting Asian traffic; the Afrikaners regarded its lands as divine
gifts wherein they could create a godly pastoral society, excluding unbelievers
and enslaving the inferior sons of Ham. In either case the area controlled by
Europeans remained basically agricultural.
Remarkable mineral discoveries changed the economy of South Africa dra-
matically. The first of these occurred at Kimberley, about six hundred miles
inland from Cape Town, where diamonds were found in 1869. European fortune
202 The Burdens of Disease

hunters and African laborers quickly poured into Kimberley, but events there
were overshadowed by the discovery of the tremendous gold fields on the ridge
called the Witwatersrand, near the Afrikaner capital of Pretoria, in 1886. Within a
few years Johannesburg, on the Witwatersrand, became one of the world’s great
boom towns. Dense populations of miners, laborers, and entrepreneurs gath-
ered in both Kimberley and Johannesburg; by 1910, 200,000 African miners
worked on the Witwatersrand. The populations of coastal towns—Cape Town,
Port Elizabeth, Durban—grew as well, as the mineral wealth of South Africa
flowed into world trade.
South Africa, therefore, experienced an unusually rapid concentration of pop-
ulation into urban centers. Immigrants poured in from Europe and Asia, and a
considerable internal migration of Africans occurred as well. Movements of peo-
ple distorted the economies of rural areas. Many of the urban workers, as min-
ers, both lived and worked in extremely hazardous conditions. For some of the
most powerful people in the society commerce rapidly assumed central impor-
tance, which might dictate state policy; yet others remained committed to the
maintenance of a white settler society, heedless of commerce and scornful of
black Africans. All these elements affected South Africa’s disease history.
Shula Marks and Neil Andersson have remarked that “[f]ar from being
some tropical inheritance, the diseases of twentieth-century South Africa—
malnutrition, tuberculosis, typhus, cholera, typhoid, VD—are the diseases of
nineteenth-century industrial Britain.”58 While that statement is true, the South
African histories of such diseases reflected some particular and colonial circum-
stances. Movements of people both to and within South Africa had special signif-
icance for disease, for example. In the course of the nineteenth century South
Africa received two different streams of European immigrants.59 By the middle
of the century consumptive Europeans, especially British, regarded the magnifi-
cent climate of South Africa as ideally restorative. If tuberculosis was not yet
endemic in South Africa (and it probably was), middle-class Europeans made it
so by creating resorts for the consumptive. The numbers of such migrants may
not have been demographically significant, but their epidemiological weight was
disproportionately large. Poor eastern Europeans, especially Russian and Polish
Jews, made up the later and much larger migration, beginning in the 1880s. They
arrived with the full complement of microbes carried by all residents of con-
gested and poverty-stricken European towns and cities, especially (again)
tuberculosis. In the burgeoning cities of South Africa they met African laborers
and miners, recruited from what had been a rural population (and in fact
Transvaal law had barred Africans from living in European towns), arriving in
the cities after a difficult journey, perhaps on foot with pauses at overcrowded
camps, perhaps on similarly overcrowded trains. After a period of brutally hard
mine work some of these Africans would return to their rural homelands.
Disease, Medicine, and Western Imperialism 203

All these circumstances clearly facilitated the spread of epidemic diseases,

and when epidemics arose the sometimes-conflicting economic and social goals
of the governing classes added interesting epidemiological complications. The
1882 smallpox epidemic that began in Cape Town displayed the differing pres-
sures of commerce and racial segregration. The mine owners first feared that
the disease would reach Kimberley, and to prevent its spread there instituted a
rigorous quarantine of traffic from Cape Town. “Hijacking travellers for fumiga-
tion at the expense and behest of the mining companies,” note Marks and
Andersson, would be a “useful precedent” for the future South African state.60
But the Kimberley diamond lords, with little practical control of routes to town
apart from the railroad from Cape Town and with no desire to cut off the move-
ment of African labor to their diggings, could not prevent smallpox from reach-
ing Kimberley. When it did they attempted to deny its presence, fearing that
others would not send them labor or food. Edmund Sinclair Stevenson, a Cape
Town physician, provided the necessary reassurance. “If it was smallpox, a quar-
antine would be called, the result being that the comparatively large population,
mostly niggers and others, would be thrown out of work. . . . Needless to say we
pronounced it chicken-pox, otherwise it might have led to serious trouble.”61 It
was more important to keep Africans at work than alive.
But as a rapidly urbanizing society at the end of the nineteenth century, South
Africa’s greatest epidemic problem was tuberculosis. The combination of
European immigrants with a high level of tuberculosis infection and Africans
with high susceptibility to the disease set up a dangerous situation, especially
when—as was true in the 1890s—those populations often lived and worked in
close proximity with each other. Many factors increased the susceptibility of
Africans to tuberculosis. The disease was probably not new to the indigenous
South Africans in the nineteenth century, but their rural and thinly settled popu-
lation could not sustain tuberculosis at the epidemic level; relatively few people
therefore had hereditary experience with it. The demand for mine labor rapidly
outstripped its supply, and recruiters scouring the villages could not be fussy
about the health of potential miners. Many of the recruits came from some dis-
tance to reach Kimberley or Johannesburg, and the journey itself might be weak-
ening, involving long walks and nights in overcrowded (and disease-ridden)
labor camps, or extended trips on similarly overcrowded trains. Many African
laborers therefore arrived in the instant cities in imperfect health.62
But conditions of life and work in the mine towns played a larger role. Miners
worked in close contact in conditions of minimal ventilation. European miners in
South Africa sometimes were tubercular, and more often suffered from silicosis,
even before they began working in Africa; it was among them that the African
miners worked. The introduction of water-fed drills in mines cut down the
dust and hence the silicosis, but created a moister atmosphere in which the
204 The Burdens of Disease

tuberculosis bacillus moved easily from one person to another. The wages of
miners remained low, for mine owners had devoted many of their resources to
capital equipment and acquisition and so claimed that little was left for workers’
wages; eventually white miners were able to wield political power, but black
Africans were shut out by governments committed to maintaining the privileges
of a white settler society. African miners were housed in overcrowded barracks;
in response to worries about lack of fresh air, such barracks were often opened
to drafts, which caused the miners (sometimes migrants from warmer climates)
to cluster close together for warmth (and tubercular infection).
In these conditions mortality from tuberculosis soared. Mortality rates from
tuberculosis for black Africans reached 1,500 per 100,000 in Port Elizabeth in
1900; although rates were lower in Johannesburg, Randall Packard believes that
the policies of mine owners masked the true extent of the disease in mine
towns.63 The mine companies saw certain advantages in a transient work force
that worked for a time and then returned to home villages. If nothing else such
“seasonal” labor required less “paternalistic” care; mine owners could excuse
barracklike housing on the grounds that the workers regarded their places as
temporary anyway, and caring for long-term illness might be left to the families
in villages. And while some African miners fell victim to the rapidly fatal “fulmi-
nating” tuberculosis, many others became more chronically ill away from the
mines. This movement of miners also contributed both to further diffusion of
tuberculosis back in the villages and to keeping a reservoir of relatively unex-
posed laborers flowing into the mines.
In this period “South Africa” consisted of several separate political entities.
Kimberley lay within the territory of the Cape Colony, in the British Empire but
possessing a fair amount of self-government dominated by Europeans; until 1902
the Witwatersrand was in the Transvaal Republic, in some theoretical sense
under British suzerainty but in practice ruled by Afrikaners. After that date the
Afrikaner states of the Transvaal and the Orange Free State fell directly under
British rule, until all the separate British holdings in the area were federated in
the Union of South Africa in 1910. Although differences in degree existed among
different political authorities, none of them had much interest in political rights
for black Africans. Prior to about 1900, political and public health leaders hoped
to educate the native workers out of their “bad habits”; they should, for example,
give up their inappropriate Western clothing, which they persisted in wearing
even when it got cold and wet; they should realize that slums were unhealthy,
and not live in them.
Then came another and more frightening disease: plague, which appeared in
Cape Town in February 1901. Fear of this disease energized South African
governments to the new public health policy of “sanitary segregation.” Separate
communities should house the dangerous Africans, apart from the European
Disease, Medicine, and Western Imperialism 205

populations of the cities; in 1901 a “location” was hastily constructed outside

Cape Town for some 6,000 Africans. Maynard Swanson has shown that this solu-
tion emerged from a context in which the segregration of Africans had been pro-
posed as a means by which employers could gain greater social control over their
work forces; in 1899 the Cape Colony had passed a “Native Labour Locations
Act” with that intent, and another law in 1902 extended government powers to
create such “locations.” The extent to which concern for sanitation and public
health may have been a simple gloss on racial prejudice and social control was
suggested by the statement of A. J. Gregory, medical officer for the Cape Colony:
“Indeed if only the sanitary condition of the premises is to form the basis of the
decision then practically a very large number of Natives could be allowed to
reside in Cape Town.”64
The segregation policy neither worked very well nor helped control disease.
At least in the years right after 1902, segregation of the work force met much
economic opposition. Employers did not like to see their workers isolated too far
from their jobs, and too many black Africans (at least in Cape Town) had become
property owners themselves and resisted compulsory resettlement. Native towns
could also spring up outside the official locations, over which the authorities had
little control; and questions of costs arose between the colonial and municipal
governments, mirroring conflicts in India. So many African laborers remained
outside the “locations,” while for those in them health conditions did not
The South African experience, though it differed in significant ways from the
other imperial illustrations in this chapter, confirms some general points.
Imperial governments could only partially control public health; private eco-
nomic interest did not always coincide with proclaimed state policy; medicine
could be a justification for stronger social control, but at times that control fal-
tered anyway, and eradication of disease rarely followed. Tuberculosis in South
Africa began declining among the European population by 1912–1914, and while
Africans and “colored” briefly shared in that decline, World War I brought a more
comprehensive industrialization, intensified urban crowding, and for the non-
Europeans, increased residential segregation and poverty. With those phenom-
ena tuberculosis rose again, now joined by serious epidemics of typhus in
1917–1924, 1933–1935, and 1944–1946. South Africa was indeed reprising the
disease history of an industrializing society.

“Tropical Diseases”
Early European attempts to reach into the interior of the tropics, espe-
cially in sub-Saharan Africa, had been repeatedly thwarted by the assaults of
malaria, yellow fever, and diseases that assailed European livestock. Tropical
disease frustrated occasional Portuguese efforts to reach up the Congo or
206 The Burdens of Disease

Zambezi rivers in the sixteenth and seventeenth centuries, and such troubles
persisted into the eighteenth and early nineteenth centuries as well. Willem
Bolts, a Dutchman in the service of the English East India Company, put 152
Europeans ashore at Delagoa Bay (Mozambique) in 1777; by 1779 only 20 sur-
vived. In Mungo Park’s 1805 expedition to the Niger all 44 Europeans died;
Macgregor Laird, pushing to the same river in 1833, fared little better, losing 39
of 48.65 This European frailty in the tropics meant that Western powers main-
tained their military presence in Africa and the Indies only tenuously, and at con-
siderable human cost to their troops.66 Philip Curtin’s tables of “relocation costs”
dramatically illustrate the differences between mortalities in Europe and in the
tropics for European military personnel. Whereas deaths per thousand of troops
stationed in Britain, France, or the northern United States in the 1820s and 1830s
varied between 15 and 20, for French troops in Algeria it was over 78, in
Guadeloupe about 107, in Martinique about 113, and in Senegal over 164. British
troops fared no better, suffering death rates of 71 in India, 130 in Jamaica, and a
dreadful 483 in Sierra Leone. Obviously maintenance of a colonial tropical empire
required serious sacrifices of manpower. And sometimes diseases contributed to
the collapse of an entire imperial holding, most dramatically in French Saint
Domingue (Haiti). In the early 1790s the Haitians had won considerable inde-
pendence from the French, and retained it despite the complications of an inva-
sion of British troops. When Napoleon Bonaparte, then consul, attempted to
regain control in 1802, the French army was overwhelmed by a combination of
Haitian resistance and yellow fever, so that by 1803 Bonaparte abandoned the
French claim altogether.
Between the 1830s and the first decade of the twentieth century the tropics
lost most of their terror for European travelers, and the steep gradient of death
rates that European troops or administrators faced when posted to Africa or the
Indies fell away. Both preventive environmental measures and therapeutic med-
ical responses contributed to this dramatic demonstration of Western cultural
power. And while the germ theory did intercede powerfully at the end of the
period, earlier measures had already had important effects.
Europeans in those warmer climates faced several different disease problems.
Some were relatively familiar though in some cases intensified: dysentery and
diarrhea, and cholera, especially in its endemic Indian home. As was true in
Europe, those diseases lost some of their grip with the gradual extension of
improved water and sewer systems, improvements first extended to European
settlements and military cantonments. Sewer systems that used water to flush
wastes out were fairly easily installed in island locations such as the West Indies,
where they simply ran into the sea. In India, however, the “dry earth” method
(related to the ancient Indian latrine system) persisted. The use of sand filters
for water purification also began in the middle of the nineteenth century,
Disease, Medicine, and Western Imperialism 207

although the rationale for their effectiveness was only demonstrated in the 1880s
by Robert Koch. The imposition of these new water and sewer systems resulted
in declining incidence of the waterborne diseases, although it may have also con-
tributed to a surge in typhoid fever in both Europe and elsewhere; sewage in
rivers increased, and unscreened sewage (to which flies had access) remained
in dry systems.67
Although cholera was in some sense a “tropical disease,” the institutes
founded for the study of “tropical medicine” in the 1890s concerned themselves
more with malaria, yellow fever, schistosomiasis (bilharzia) and other worm
problems, and sleeping sickness. Of these malaria and yellow fever were the
great barriers to European movement in the tropics. The two posed different
problems, although they were often lumped together and diagnoses of them
were often imprecise. Malaria is a chronic ailment caused by species of the genus
Plasmodia. These protozoa are carried from person to person by mosquitoes of
the genus Anopheles, which includes hundreds of species (although relatively
few are important malaria vectors). Several different species of Plasmodia pro-
duce different forms of malaria, of differing degrees of severity. The disease
therefore includes a spectrum of symptoms, made wider by its chronic charac-
ter; degrees of debility vary widely from time to time in the same individual. Its
epidemiology is a complex tangle involving several different causative parasites
and a larger number of insect vectors that may flourish in different environments,
as well as different levels of human resistance.
Malaria had a long history in parts of Europe and North America, and it was
only in the nineteenth century that Europeans began to consider it a “tropical”
disease at all. As Randall Packard has argued, that happened, in part, because
changes in methods of agricultural production in turn led to ecological changes
that affected malarial environments. Those changes themselves were ultimately
the outgrowth of Western political and economic power and modernization. With
agricultural development, areas in the Western world that had been malarial
became less so, while areas of Asia and Africa introduced to systems of Western-
controlled plantation agriculture became more so. Many imperial agricultural
enterprises involved large labor forces (often seasonal or migratory), little tech-
nological investment, deforestation, and haphazard irrigation systems, all of
which led to both poverty for the workforce and environmental change that
favored malaria.68
Eradicating all of the relevant Anopheles mosquitoes has proved to be extraor-
dinarily difficult. But in the seventeenth century (see Chapter Six) the Western
world had learned of an indigenous South American remedy—cinchona bark—
that had both curative and preventive powers. In the early nineteenth century
quinine, the chemically active component of cinchona bark, was isolated and
came into increasing Western use by the 1830s. Daniel Headrick lays great
208 The Burdens of Disease

weight on quinine as a prime tool of empire that made the tropics safe for
Europeans. Philip Curtin, more cautious, sees quinine use working together with
improved drainage in European tropical stations, but both agree that European
mortality from malaria in the tropics declined rapidly in the years between 1840
and 1860. Morbidity may have remained higher, since quinine could not entirely
prevent Plasmodia from entering bodies, and drainage schemes (as we shall see)
were often incomplete, especially away from easily managed island environ-
ments. The connection between malaria and mosquitoes was made only in the
1890s, so drainage had no precise target; malaria had for centuries been the
definitive “miasma” disease, and was then associated with general “filth” by
nineteenth-century sanitarians. Alphonse Laveran found the plasmodium in 1880;
Patrick Manson began showing the role of insects in filariasis in the late 1870s;
Ronald Ross completed his arguments that connected Plasmodia and Anopheles
in 1898.
Yellow fever, an acute viral disease, posed an immediate short-run threat to
European lives, for its mortality rate could rival that of plague. But some features
of its epidemiology meant that it was both less widespread and easier to escape
than malaria, and so its demographic effect was less. Yellow fever—again like
plague— exists primarily as an enzooitic disease, in its case usually in forest pop-
ulations of monkeys. It occasionally and endemically reaches humans from the
monkey population, through a mosquito vector. Yellow fever becomes epidemic
in human populations when mosquitoes carry it from one human to another.
Several factors limit its spread. The principal vector, the single mosquito species
Aedes aegypti, has domestic habits close to human dwellings, a short range of
flight, and a constant need for water and warmth. Cool weather or dry conditions
will therefore halt an epidemic, and some Europeans and North Americans
escaped yellow fever by simple flight, as British troops did in Guyana in 1861.
And the acute character of the infection also limited its spread. The symptoms of
the disease in fact vary widely, although many cases can be dramatic and the
mortality rate may be high; many children in sub-Saharan Africa or the West
Indies probably contracted mild cases that conferred subsequent immunity, and
thus the disease might run out of unexposed humans and “burn out” fairly
quickly, and so either die out or return to the enzooitic state in the neighboring
If malaria was a chronically debilitating (and sometimes fatal) problem,
yellow fever remained in the nineteenth century an occasional terror. Any
Western city maintaining a trade connection with the West Indies was especially
vulnerable, if a ship carrying the virus and Aedes aegypti arrived in its harbor.
Philadelphia suffered in 1793 (see Chapter Six), Barcelona in 1821, New Orleans
in 1853, St. Nazaire in 1861, Swansea in 1865, Memphis in 1878. To unexposed
Europeans in Africa or the West Indies yellow fever was extremely dangerous,
Disease, Medicine, and Western Imperialism 209

and quinine had no effect. In the earlier nineteenth century the incidence of
yellow fever may have been reduced by flight and by some swamp drainage,
although the first was more often an intuitive than a reasoned response and the
second was undertaken usually as part of a broad-spectrum assault on the gen-
eral causes of “miasma.” Then in the late 1870s the Cuban physician Carlos
Finlay y Barres advanced the theory that mosquitoes—specifically Aedes
aegypti—transmitted yellow fever; apparently Finlay got the idea of the mos-
quito’s role from Patrick Manson, who in 1878 had argued that mosquitoes car-
ried (or “nursed”) embryonic filariasis. But Finlay’s epidemiological theory was
not followed up until 1900. As François Delaporte argues, the intervening
decades of the 1880s and 1890s were dominated by zealous bacteriology, which
encouraged a search for the causative organism of yellow fever as well as for
most of the other ills of humankind.69 Yellow fever—a viral disease—defeated
the bacteriologists, while interest in possible vectors waned.
In 1898 bacteriology enjoyed one of its great triumphs, when Ronald Ross
showed that some mosquitoes carry (as intermediate hosts) malaria Plasmodia.
Two British researchers in Havana, H.E. Durham and Walter Myers, first saw
the analogy between Finlay’s vector theory of yellow fever and Ross’s intermedi-
ate hosts in 1900. Havana at that point was effectively under United States con-
trol, in the wake of the American war against Spain in 1898; American military
physicians, following the lead of Durham and Myers, pursued a possible yellow
fever–mosquito link with a series of risky experiments, in the course of which
one of them (Jesse Lazear) died of yellow fever after being bitten by an infected
Aedes aegypti mosquito. Later in 1900 Walter Reed repeated these experiments
(and won more historical acclaim), and Reed’s work convinced American and
Cuban authorities that the answer to yellow fever epidemics lay in the eradica-
tion of Aedes aegypti. The subsequent assault on possible breeding places and
homes of that insect yielded spectacular results, as the incidence of yellow fever
(and malaria) in Havana plummeted.70 More dramatic American military success
was to follow, in Panama.
The American conquest of the environment in Panama has often been told as
perhaps the greatest “triumph” of Western imperial health. But its historical les-
sons are not simple, and its consequences for other imperial health policies were
mixed. A French company had begun working on a canal across the seductively
narrow isthmus in 1881, but it encountered tremendous difficulties, not the least
of which were the ravages of malaria and yellow fever on its work force. (The
company might have expected this, for the laborers who built a railroad across
the isthmus in the 1850s had been similarly decimated.) The canal work was
abandoned in 1889, with the company bankrupt and the number of deaths (even
then very uncertain) in the thousands. Driven by its experiences in the 1898 war
with Spain, the United States government saw the advantages in quickly
210 The Burdens of Disease

connecting its naval units in the Pacific and the Atlantic, and so it acquired the
French diggings in 1904 and began its own canal, completed in 1914. The eradi-
cation of yellow fever and malaria from one of the most malarial places on earth
made that success possible.
The eradicator, William Gorgas (an American army physician), had begun a
huge and indiscriminate clean-up campaign in Havana in 1899. After the work of
Lazear, Reed, and their colleagues had convinced him of the wisdom of focusing
his attention on mosquitoes, he had done so. In 1904 he moved to Panama to
repeat his methods. Those methods depended on a massive military-style assault
on a community, fumigating property, screening houses, and above all attacking
mosquito breeding grounds by draining swamps and puddles, clearing vegeta-
tion, and lavishly spreading such possible larvicides as carbolic acid and caustic
soda. In Panama Gorgas was given a large budget and a substantial work force.
The results were startlingly successful: the last yellow fever epidemic was in
1905, while malaria mortality quickly declined (from 40 per thousand in 1906 to
9 per thousand in 1908) and so did morbidity (from a frightening 800 per
thousand in 1906 to only 16 per thousand in 1916).71 But the costs were stagger-
ingly high. George Goethals, the engineer in charge of the American canal con-
struction, told Gorgas that every mosquito he killed cost ten dollars. 72 The
wealthy United States might spend that, in a relatively small area of unusual
importance for both national security and commerce; but even the vast British
Empire had no chance of duplicating such expenses across (for example) the
subcontinent of India.
Nevertheless the eradication model, so successful in Panama, drew imitators.
At the very least, the same enthusiasm that seized Americans in Cuba and
Panama, an enthusiasm for combining the genius of bacteriology with that of
engineering, worked elsewhere as well. Across the British Empire different ter-
ritories began attempts to eradicate mosquitoes. Ronald Ross arrived in Sierra
Leone with high hopes, believing that draining about one hundred puddles would
eliminate malaria from Freetown. By 1901 he realized that the job was bigger,
and he began a more elaborate drainage campaign. But dramatic Havana results
were not obtained, perhaps because Sierra Leone was far more malarial than
Cuba to begin with. The Royal Society of London’s Malaria Commission shied
from the prohibitive costs of eradicating mosquitoes in Sierra Leone and instead
recommended a system of residential segregation, which would at least isolate
the Europeans from the fever-infested natives. A hill town outside Freetown was
constructed and the eradication campaign was abandoned. In populous Nigeria
the British authorities reached the same conclusion: improving the health of the
indigenes simply cost too much. In India, where some local self-government
existed by 1900, the size of the problem defeated the willingness of governments
to raise money to meet it. An extensive and expensive attempt was made, for
Disease, Medicine, and Western Imperialism 211

example, to drain irrigation canals around the military cantonments of Lahore

between 1901 and 1909. It failed, which increased the Indian government’s con-
viction that protecting native quarters was hopeless; all the more so since the
indigenously elected local councils proved their incompetence (at least to
Europeans) by refusing to raise money for sanitation.73
Segregation, as a cheaper “remedy” than a costly Panama-style eradication,
was pursued by other European powers as well. In 1910 the German rulers of
Cameroon proposed to relocate the entire indigenous population of Douala
inland, leaving the coast for European settlement. And in Dakar (Senegal) the
French authorities decided that the Africans followed lifestyles that were incom-
patible with European standards of sanitation. Daniel Headrick points out that
some of these unsatisfactory lifestyles in fact grew out of poverty and differential
treatment.74 When the French built up Dakar as a naval station between 1898
and 1908 they lavishly supplied the city with water from newly dug wells, but
most of the water was reserved for the harbor and military installations and for
European residences; Africans in the rapidly growing town had to husband their
water carefully in barrels that became homes for mosquitoes. On such grounds
the French justified residential segregation, although they agreed that Africans
who obeyed European sanitary rules could live in European quarters.
Segregation in Dakar was therefore based on habits, not race, although a racially
based decision about water supply helped create the “habits.” South African argu-
ments remained more purely racial. As we have seen, a sense of emergency gen-
erated by the appearance of plague there in 1900 led to plans for residential
segregation, and Maynard Swanson argues that this “sanitation syndrome”
became a useful support for social control founded on racial prejudices.75
These different African and Indian examples illustrate that other remedies
might vie with the wholesale (and prohibitively expensive) eradication of mos-
quitoes by drainage. Laboratory science also offered other alternatives: therapy
(both preventive and curative) and the chemical assault on insects, as opposed
to the massive engineering works of Panama drainage. As we have seen, quinine
could both deter malaria and contribute to its cure. Angelo Celli, the influential
Italian student of malaria, came to believe that widespread quinine treatment
was the surest antimalaria path, and Robert Koch agreed. Chemical insecticides
gained favor in the years after World War I as another eradication technique.
Still another road was not often taken: the improvement of the living conditions
of masses of working people. Malaria and yellow fever, like cholera and
tuberculosis, might truly have been seen as diseases of poverty, rather than
“tropical diseases” that came with the supposedly savage and backward. Before
World War I Celli suggested that if people could afford adequate diets and good
homes with screens to bar mosquitoes, then mosquito-borne diseases could be
overcome. But biomedicine was easier than social reform.
212 The Burdens of Disease

In the nineteenth century Western imperialism both spread diseases
and altered the human and natural environments in which diseases existed. In
those respects imperialism qualifies more as human disaster than as human
The West did achieve some limited or mixed successes in the “conquest” of
diseases elsewhere in the world. Most dramatic were several campaigns, based
largely on mosquito eradication, against yellow fever and malaria. Yellow fever,
carried by one fairly domestic species of mosquito, proved easier to attack than
malaria, borne by a number of species of varied ranges. Truly effective insecti-
cides came after World War I, and their results—again mixed—will be seen in
Chapter Eleven. Cholera, like dysentery and typhoid, was being brought under
control by sanitation methods in the West, but those measures only slowly
extended to areas under Western control elsewhere. Many Westerners were
convinced that the “natives” were hopeless about such amenities and so extend-
ing sanitation was futile; Western colonial governments often had little money to
spend, or were caught in wrangles about who should bear costs; indigenes some-
times resisted the changes in ways of life or systems of property that sanitation
entailed. Plague inspired excited reactions, but until after 1900 those reactions
consisted of unfocused “clean-ups”; more effective attacks on rodent vectors only
began after World War I. Western-imposed quarantines did help in some cases,
but often only after the horse had left the barn; measles in Fiji became less seri-
ous largely because the population acquired exposure to it.
If many of the “tropical diseases” (and others) persisted in the Western impe-
rial world, it was largely because economic and social conditions, especially
poverty, persisted or were deepened by colonial rule. Plague, typhus, cholera,
tuberculosis, malaria, trypanosomiasis, and hookworm diseases all flourished
where people lived in close proximity, where houses could be easily invaded by
mammal and insect disease vectors, where water supplies could be tainted by
sewage, where nutrition was inadequate, where people worked in bare feet.
Larger dwellings more solidly constructed, screened windows, iron pipes, ade-
quate reservoirs, varied diets, and shoes were marks of prosperity. Western colo-
nial rule eventually tried to justify itself by claiming to promote economic
development, but in the nineteenth century it was most often simply exploitive.
But even with the best will, the Western imperial governments could not
impose a clear vision of health on the lands they ruled. Policies could too often
inspire internal conflicts between those who wanted to publicize disease
(whether in Kimberley or Bombay or, for that matter, in San Francisco) and
those who wished to preserve commerce, between those who wanted vigorous
action and those who feared indigenous reactions to it, between those who
favored the focused attack made possible by bacteriology and those who wished
Disease, Medicine, and Western Imperialism 213

to continue (or revive) a general environmentalism. The ability or even compe-

tence of much colonial medicine was not clear even then. Ronald Ross “had no
predilection at all for medicine,” and only became a physician because that would
“allow him leisure for shooting and riding and other such hobbies”;76 William
Gorgas only became a physician after he failed to gain admission to a military
academy. Western physicians in the imperial world did not all model themselves
on the saintly David Livingstone; Leander Starr Jameson and Frederick
Rutherfoord Harris took leading roles in the looting of Rhodesia. And even if the
rulers could agree among themselves and could employ able and disinterested
medical practitioners, it remained true that (as Megan Vaughan puts it) colonial-
ism had a “limited impact on cultures and the identities they created.”77
Biomedicine’s greatest triumph by the end of the nineteenth century was
probably over the European mind. Europeans were convinced that they under-
stood the causes of diseases and could take at least preventive action against
them, either through immunizing vaccines or through interrupting the vectors
that carried microbes. This knowledge elevated them, they believed, above other
“lesser breeds” of humanity, whose diseases could be explained perhaps by biol-
ogy but increasingly as the products of ignorance and hence human failure. The
development of this confident biomedicine forms a theme of the next chapter.

The Scientific View of

Disease and the Triumph of
Professional Medicine

A t the beginning of the nineteenth century physicians occupied an

uneasy position in the world of Western healing. Although they still possessed
many privileges, in practice the distinctions between them and other healers
remained unclear. Thus while physicians belonged to corporate bodies that
enjoyed privileges recognized in law, surgeons and apothecaries had begun
establishing similar claims; for the most part graduates of universities, physi-
cians enjoyed the status of a learned profession, which elevated them above
craftsmen (such as surgeons) and tradesmen (such as apothecaries) in Western
social hierarchies, but in at least some places such distinctions were losing their
force. Two factors in particular had contributed to fraying the boundaries of the
physician’s authority. It had proved very difficult—in practice—to enforce the
privileges of any one corporate body of healers, particularly in an age when
no one group possessed any clear therapeutic advantage over others. Especially
in western Europe and North America the eighteenth century was also an age of
an increasingly vigorous entrepreneurial economy, which made the maintenance
of monopoly hard to sustain; this free market competition had particular force in
the health business, where consumers often dictated the terms of service.
Nineteenth-century developments would greatly strengthen the professional
position of physicians. In the course of the century increasingly tight connec-
tions were drawn between a physician’s education and a license to practice
awarded by the state, a license that eventually depended on completion of an
“appropriate” education or even on an examination administered (or authorized)
by the state that confirmed the results of that education. States gradually recog-
nized exclusive rights to practice healing by employing different sanctions
against those who fell outside the charmed (that is, the educated and licensed)

The Scientific View 215

circle. These changed circumstances were partly the product of political forces
and partly the result of pressures from within communities of physicians and
other healers, as an examination of several national cases will show. But
physicians’ changing relationship to science also improved their position, as did
changing perceptions of the curative power of the remedies that physicians
By the second half of the nineteenth century science had come to inspire enor-
mous confidence in its explanatory power. Enthusiasts for science had promoted
its virtues in the seventeenth and eighteenth centuries, so by the nineteenth a
well-established tradition of scientific faith existed. In the nineteenth century,
furthermore, science shared the prestige and evident success of industrial tech-
nology, in an age when (for a large complex of reasons, including science’s suc-
cess) religion slowly lost some of its hold on beliefs. Medicine both benefited
from and contributed to the perception of the power of science, for not only could
technology conquer distance, scientific medicine could conquer disease.
Winwood Reade’s The Martyrdom of Man (1872) may stand as an extreme
example of the faith:

The God of Light, the Spirit of Knowledge, the Divine Intellect, is gradually
spreading over the planet and upward to the skies. . . Disease will be extirpated;
the causes of decay will be removed; immortality will be invented. And then,
the earth being small, mankind will migrate into space, and will cross the
airless Saharas which separate planet from planet, and sun from sun. The earth
will become a Holy Land which will be visited by pilgrims from all the quarters
of the universe. Finally, men will master the forces of Nature; they will become
themselves architects of systems, manufacturers of worlds. Man then will be
perfect; he will then be a Creator; he will therefore be what the vulgar worship
as a God.1

Physicians may not have been gods by the end of the nineteenth century, but the
triumphs of science (especially the newly articulated germ theory) conferred on
them powers that to some seemed little short of miraculous.

Changing Professional Situations

The professional situation of physicians first changed clearly in France.
In the 1790s the revolutionary governments scrapped the ancient universities—
including the traditional university training of physicians—and created a new
national system of higher education. For medical education the new schooling
meant a closer relationship between the educations of physicians and of sur-
geons than had previously obtained. Although (as Chapter Six suggested) the
changes may nave been more gradual than revolutionary, the education of physi-
cians now included more first-hand experience of anatomy and physiology and
216 The Burdens of Disease

more clinical practice in a hospital setting. Then in 1803 Napoleon Bonaparte’s

Consulate enacted new laws providing for a uniform licensing system for physi-
cians, surgeons, and “health officers”; a state license depended on completion of
a specified number of years in the new state medical universities, followed by
a state examination. This uniform, national system (national for the physicians
and surgeons at least) replaced the tangle of old regionally based corporate priv-
ileges and monopolies that had grown up prior to the Revolution. Those respon-
sible for the legislation intended to draw a much sharper line between licensed
and “irregular” medical practitioners than had obtained in the past. Nevertheless
the 1803 laws did not change the French medical world overnight. Numerous
loopholes remained, through which more irregular practitioners slipped to con-
tinue their careers; French physicians only slowly developed institutions that
might control professional positions; and university-trained physicians remained
the representatives of an elite subculture, not widely trusted by the general popu-
lation. But the system of state licensing and control imposed a measure of unifor-
mity, and when (later in the century) dramatic new therapeutic science appeared,
it could be adopted by a profession that had already been given a shape, defined
by a common state-imposed educational, examination, and licensing process.2
In the German states a bewildering assortment of privileged bodies existed in
the eighteenth century, if only because there existed a bewildering assortment
of over three hundred states. After the drastic political rationalizations of the rev-
olutionary and Napoleonic eras, Germany in 1815 still contained thirty-nine sov-
ereign states. In at least some of these the structure for an organized and
monopolistic medical profession already existed, for many contained universi-
ties that were (and had been for some time) under state control; their medical
graduates might be automatically licensed to practice. But would states desire to
give physicians privileged powers of monopoly? In the eighteenth-century
German states the traditions of enlightened despotism and cameralism had won
important adherents, more so than in France or Britain. Those traditions might
mandate an active and perhaps intrusive state role to increase a ruler’s wealth
and power, and thus support state public health regulation. Johann Peter Frank’s
multivolumed treatise on “medical police,” published between 1779 and 1819,
urged states to license physicians, to regulate or suppress irregular healers, and
to employ physicians as state health officers. Early nineteenth-century German
states proved more or less eager to follow Frank’s advice, and if they did the
prestige and monopoly position of physicians increased. But the issue was never
clear, for the rival liberal ideology urged the virtues of free competition, which
left much room for irregulars. The ultimate unification of the German states
under the aegis of the kingdom of Prussia occurred at a time (1866–1871) when
many physicians opposed state restrictions, yet as their numbers increased by
the 1880s they pressed for greater power to restrict the market.3
The Scientific View 217

In both Great Britain and the United States the legal position of the medical
profession was much less clear in the early nineteenth century. In Britain a num-
ber of privileged bodies existed for physicians, surgeons, and apothecaries, some
of considerable antiquity; the (English) Royal College of Physicians had been
chartered in 1518. But their powers were slight. The Royal College of Physicians,
the most prestigious, was only empowered to license physicians within a seven-
mile radius of London. The college was prone to insist—largely to maintain the
gentlemanly aspect of a “profession”—that its members be graduates of Oxford
or Cambridge universities, where in fact little serious medical education was pur-
sued; and while possessors of Oxford or Cambridge medical degrees might prac-
tice medicine anywhere in the United Kingdom, little or no legal machinery
existed to prevent other practitioners from competing for the trade. Among the
members of different corporations (physicians, surgeons, apothecaries, from
England, Scotland, or Ireland) lively professional rivalries and jealousies per-
sisted. Only in the nineteenth century did these different bodies, with some assis-
tance from changes in the law, begin to demand meaningful qualifications of
their members. In the years after 1800 the College of Surgeons began imposing
on aspiring members specified terms of apprenticeship, as well as an education
that included attendance at a number of lectures. In 1815 the Society of
Apothecaries obtained, through a parliamentary statute, powers of licensing that
included setting an educational standard and examining candidates for profi-
ciency. But it was not until 1858 that the British government created a legal cate-
gory of “licensed medical practitioner.” The license, it was true, could be granted
by any one of a number of corporate bodies, on the model provided for the
Society of Apothecaries in 1815; but the registration of the licensed was placed in
the collective hands of a “General Medical Council,” on which the medical cor-
porations and the universities were represented, and that body had the further
power of striking off the registered lists those whom it deemed unqualified.
Although British law still did not outlaw irregular medical practice, only regis-
tered healers could be employed by government bodies, and after 1858 unli-
censed practitioners might be liable for criminal prosecution for assault or
manslaughter if their patients wished (and were able) to complain.4
The legal powers of physicians in the United States were murkier still. In the
colonial period no privileged corporations for the healing professions existed
(except those from Britain whom the colonists chose to recognize), and so
“doctors” were entirely self-described. In the 1760s some of the colonies began
attempting to license physicians, but without any agreement as to uniformity of
training. Medical schools in British America also began in the 1760s, but
American physicians continued to acquire their credentials by a varying combi-
nation of apprenticeship and attendance at lectures at such a college; others
simply started practice as “physicians” with no formal training at all. Hostility to
218 The Burdens of Disease

the claims of a privileged guild remained strong in the young United States, so
much so that by the period between 1820 and 1850 those American states that
had previously attempted to license physicians gave up the effort. In the mid-
nineteenth century, therefore, American medical practice was entirely unregu-
lated, and a wild variety of healers, expounding different philosophies, competed
for the public favor. Then between the 1870s and the 1890s a growing number
of American states began conferring increasing powers on physicians, who
could be licensed if they earned a diploma from a medical college. The states
gradually assumed the power to determine the validity of the diploma and/or to
insist that physicians seeking a license pass a state examination that would
validate their medical education. As Paul Starr says, those steps evolved
“incrementally” in the late nineteenth century, so that by the beginning of the
twentieth the American physician occupied roughly the same legal ground as
his European colleague.5

“Science” and Medical Practice, 1800–1860

Shifts in scientific ideas and technical medical practice may partly
account for the emergence of the physicians’ professional monopoly. Between
1800 and about 1860 the beliefs of “orthodox” physicians changed considerably,
although how those new beliefs affected what physicians did was not so clear.
At the beginning of the nineteenth century most physicians were aware that the
Galenic paradigms that had dominated their profession for centuries were of
doubtful value. Galenic anatomy—and even more Galenic physiology—had been
discredited for some ever since the time of Harvey in the seventeenth century.
The Galenic humoral theories had likewise come under heavy fire; since the
sixteenth century different arguments had been made for the local (as opposed to
the systemic) origin of disease, and those localist beliefs had acquired particular
force by about 1800, especially in Paris, then the most important center of
Western medical ideas.
But the Galenic paradigm had not yet been replaced by another that had won
general assent, and the therapies offered by orthodox physicians remained
essentially Galenic, in that they aimed at the immediate relief of visible symp-
toms by manipulation of body fluids. Bleedings and purgings with that end in
view remained the order of the day for the early nineteenth-century physician,
however much he might have forsworn allegiance to Galenic humors. Thus
Broussais, a fervent exponent of the local character of disease, found all disease
to be a product of malfunctioning solid tissue, and urged that those malfunctions
be relieved by bleeding. Benjamin Rush, the influential American physician,
proposed another “unitary” theory of disease, which he believed to be based on
“capillary tension.” Bleeding ameliorated such tension. The use of the lancet
and the prescription of such powerful purgatives as calomel symbolized early
The Scientific View 219

nineteenth-century medicine, so much so that an important British medical

journal founded in 1823 bore the simple (though politically meaningful) title
The Lancet.
This view of the importance of local sites for explaining disease, still uncer-
tain at the start of the century, gained much strength between about 1800 and
about 1860 as a result of experimental evidence and arguments. That evidence
was most important in pathology, where it gained weight incrementally and grad-
ually. Xavier Bichat, one of the most vigorous proponents of a local view of dis-
ease, was also an enthusiastic pathologist. Spurred by his belief that disease
affected individual tissues, not organs as a whole, Bichat performed a remark-
able number of autopsies in a few years of work before his premature death in
1802. In the next fifty years a large body of pathological knowledge accumulated.
One of Bichat’s Parisian successors, P. C. A. Louis, used his considerable patho-
logical experience to urge the creation of a “numerical” medicine in which con-
clusions—especially those drawn from pathology—should be formed from
statistical evidence. In Britain the availability of corpses for dissection and
research was put on a legal footing by the Anatomy Act of 1832. That act had
other political causes and consequences that will be discussed presently, but for
the moment it may be taken as a symbol of the growing strength and solidity of
anatomical research, and of the conviction that medical enlightenment and
anatomical science were closely related. In Vienna Karl von Rokitansky accumu-
lated a huge volume of pathological observations, summarized in his writings
of the 1840s.
The general pathological interest that these examples represent culminated
in the career of Rudolf Virchow, who began to make his name with microscopic
pathological studies in the 1840s. Virchow, impressed by the cell theories of
Matthias Schleiden and Theodor Schwann, focused his attention on the cell as
the heart of the pathological process, while he also came to believe that cells
themselves divide and so create other cells. It followed that a “diseased” cell
might divide and so by replication, or “mitosis,” spread disease. The implications
were clear: disease originated in microscopically local sites, and only became
“systemic” by spreading over a growing number of such sites. Virchow’s reputa-
tion as a pathologist became immense, bolstered both by the prestige of his
position as a professor at the University of Berlin, the flagship of German
Wissenschaft, and by his political renown as a leading German liberal, a partici-
pant in the Prussian revolution of 1848 and later a deputy in both the Prussian
Diet and the imperial Reichstag.
This concern with local organs and local sites of disease also manifested
itself in physiological studies, especially in the understanding of the nervous sys-
tem. The body came to be seen in an increasingly mechanical or chemical light,
while human physiological processes were increasingly subjected to deliberate
220 The Burdens of Disease

experimental manipulation. Bichat straddled old and new physiological concep-

tions, being drawn both to explaining the “vital” properties of organs (as Harvey
had been) and to regarding organs as inert subjects of experiment; surgery
might help him “analyze functional organic dependencies.”6 François Magendie
(1783–1855), in the next generation of Parisian physiologists, employed both
chemistry and surgery experimentally, isolating the chemically active principles
of substances (such as quinine from cinchona bark) and showing their actions
on body organs. A growing body of evidence, accumulated especially by
Johannes Müller in the 1830s, suggested that specific sensory nerves responded
to specific stimuli and thus gave rise to specific sensations. And by the middle of
the century Magendie’s successor Claude Bernard had shown that because the
body itself could perform the chemical synthesis of such a complex substance as
sugar, the interruption of chemical processes in the body could artifically bring
about disease. The conclusions of Magendie, Müller, and Bernard argued that
medicine might be a genuinely experimental science: chemically prepared sub-
stances could precisely affect human organs, physiologists could experimentally
tamper with nerves, pharmacologists could understand the body’s functioning
chemistry and manipulate it in detail.
The local views of disease and of the human body received futher reinforce-
ment from another quarter: the changing tools of diagnosis available to physi-
cians. At the start of the nineteenth century physicians still mainly relied on the
symptoms reported to them by patients, together with visual examination of skin
and excreta. Some thermometers existed to measure body temperature, but they
were awkward and so little used. The same could be said of watches to measure
the pulse. Percussion of the chest, introduced by Leopold Auenbrugger in the
1760s, produced diagnostically useful sounds. Then between 1816 and 1819 René
Laënnec developed the stethoscope (which he “discovered” almost accidentally).
The mercury manometer made possible more accurate readings of blood pres-
sure by the 1820s. Between 1848 and 1854 both the ophthalmoscope and the
laryngoscope came into use, allowing the examination of the eye and the larynx,
while in the 1850s Carl Wunderlich began showing the importance of systematic
records of body temperature, regardless of the clumsy nature of the available
thermometers. The convenient body thermometer, no more than six inches long,
was designed and put into use by Thomas Allbutt in the 1860s. These diagnostic
tools had several immediate effects. They allowed physicians to focus on particu-
lar parts, organs, and functions of the body, which may have both confirmed
a “local” view of disease and contributed to the growth of specialization among
physicians; an individual physician might gain a reputation for his special skill in
the interpretation of chest noises, for example. These tools also enabled their
users to pose as detached observers of the body, simply and objectively record-
ing the facts, especially if those facts were quantifiable, as body temperatures,
The Scientific View 221

blood pressures, and pulses might be. Patients thus began the long process
of putting themselves in the hands of “scientists” whose judgments depended
on “objective” measurement, not on subjective interpretations of the patients’
own reports of symptoms, reports necessarily couched in words, always suscep-
tible to shades of meaning. And the new diagnostic tools also increased the assur-
ance of physicians, which may have bolstered their prestige with the general
The introduction of new methods of anesthesia conferred further prestige on
orthodox healing in the mid-nineteenth century. Medicine here benefited from
its de facto alliance with surgery, especially in the United States (where the pro-
fessional distinctions between surgeons and physicians had never been clear)
and in France (where common education and licensing procedures had worn
such distinctions away). Between 1845 and 1855 the use of anesthetic gases rev-
olutionized surgical practice. Some forms of anesthesia had been used for cen-
turies, notably different preparations involving opium, mandrake, and/or alcohol,
but none of them could do more than moderate the horror of amputations or
deep incisions into the viscera. Some surgeons experimented with “compres-
sion” of the nerves of a limb during amputation; others hoped to use the trances
induced by “mesmerism.”
Exciting developments in anesthesia, however, stemmed from the eighteenth-
century discovery of gases. By about 1800 one of the pioneers of gas chemistry,
Thomas Beddoes, together with his assistant Humphry Davy, had learned the
curious properties of nitrous oxide, “laughing gas.” In subsequent decades
nitrous oxide was first demonstrated by the charismatic Davy in his popular
lectures at the Royal Institution in London, and its use then became a party enter-
tainment, as did the use of ethyl ether. A gas evening gave those who attended
a chance to be silly, which (as one sarcastic observer noted) may not have been
a surprise: “The first subject was a corpulent, middle-aged gentleman, who, after
inhaling a sufficient dose, was requested to describe to the company his sensa-
tions: ‘Why, I only feel stupid.’ This intelligence was received amidst a burst of
applause, most probably not for the novelty of the information.”7
By the 1840s experiments had begun on the use of such nepenthe-like sub-
stances in surgery, initially by dentists. Horace Wells of Hartford, Connecticut,
began using nitrous oxide on patients while he extracted their teeth, but when
he performed a public demonstration of the technique in Boston in 1845 the
“painless” effect was unconvincing. A Boston surgeon, William Morton,
impressed despite the inconclusive result of Wells’s trial, used ether in 1846 in
the extraction of teeth and, more notably, in the public excision of a tumor.
Morton’s demonstrations, quickly and widely reported, spread the techniques of
gaseous anesthesia to Europe, where by the end of the same year a leg had been
amputated in London while the patient lay unconscious from the effects of ether.8
222 The Burdens of Disease

In the next year the technique was extended to childbirth, with chloroform
becoming especially popular for that purpose. In 1853 anesthesia in childbirth
received the highest social blessing when John Snow administered chloroform
to Queen Victoria during the birth of her eighth child. Victoria, who did not like
the experience of childbirth, referred to “that blessed Chloroform . . . soothing,
quieting & delightful beyond measure.”9
The rapidly spreading use of anesthetics transformed surgical practice. The
previous high premium on speed in surgical procedures, requiring of the sur-
geon considerable strength, gave way to a concern for precision. Since the
patient no longer howled and writhed in agony, the surgeon could be meticu-
lous. Both the greater care of the surgeon and the painlessness of the operation
gave patients much more confidence in the prospect of surgery, and that confi-
dence redounded to the prestige of the medical profession. This confidence,
further strengthened by the gradual adoption of antiseptic methods in surgery
(to be discussed shortly), resulted in a considerable increase in the number of
surgical procedures performed and in the total of operations in general.10
By the mid-nineteenth century, then, medicine and its ally surgery could claim
greater diagnostic power and improved (and certainly gentler) surgical reme-
dies. Medicine seemed in some sense more a science, allied with chemistry and
even with physics and statistics, while the organs of the body were being seen in
a more thoroughly chemical or perhaps electrical light.

The Professionalization of Nursing

In an indirect way, the position of physicians in the eyes of the general
public may also have been improved by the changing position of and regard for
nurses, a development which ran in tandem with the professionalization of physi-
cians. Certainly the professionalization of nursing made the medicalization of
disease and its treatment in hospitals a more appealing prospect, and although
conflicts often arose between nurses and physicians over positions of power and
authority in the world of the sick, on balance the physicians benefited from the
nurses’ new dignity.
Nursing had an ancient tradition in the Western world, historically connected
with religion. Early Christian communities emphasized the care of the sick as a
virtue or an obligation, and in the medieval period religious orders (of both men
and women) performed nursing services. The Protestant Reformation, hostile to
the religious orders of medieval Catholicism, helped to fracture nursing tradi-
tions. In Catholic Europe, at least in some places and cases, religious orders
devoted to the nursing of the sick remained strong, as was true, for example, of
the Sisters of Charity founded by St. Vincent de Paul in France in the early
seventeenth century. But in Protestant states, where religious orders had been
discouraged or suppressed, nursing had generally fallen into disrepute by the
The Scientific View 223

eighteenth century. Without intangible religious compensations, nursing was a

task in which low wages combined with ugly drudgery.
Enlightenment thinkers and governments made several efforts to change
that dismal picture. The emphasis on the role of the environment in causing (or
preventing) disease obviously suggested the importance of an improved envi-
ronment for the sick. Some governments, especially in Germany, acted under
the influence of a cameralist ideology, perhaps along the lines suggested by
Frank’s “medical police”; Frank urged the state provision of nursing services
that would enforce sanitation standards. In the Rhenish Palatinate the medical
reformer Franz May founded a nursing school in connection with a hospital
in Mannheim in 1781 (in the same period in which the education of physicians
was becoming more associated with hospital experience). May emphasized
general deportment together with instruction in dietary routines, bathing, bleed-
ing, and following the orders of physicians. This training, which combined scien-
tific lectures and practical hospital life, was an essential part of May’s attempts
to create a professional corps of nurses, attempts that also included a careful
selection of applicants, the issuance of a certificate on completion of training,
and the provision of servants for the nurses. The Mannheim system established
a secular model for all future Western nursing; it spread, slowly and unevenly,
through other German states in the late eighteenth and early nineteenth
One of those German nursing centers greatly influenced Florence
Nightingale (1820–1910), the most celebrated figure in nursing history.
Nightingale, an Englishwoman of some social standing and wealth (and a great
deal of intelligence and organizational drive), found in nursing a career that
allowed her to break free of her family’s conventional assumptions about the
proper domestic role of an upper middle-class woman. Residence in the German
nursing institution at Kaiserswerth, founded by Theodor Fliedner in 1833, intro-
duced her to disciplined professional nursing. After taking the superintendency
of the Institution for the Care of Sick Gentlewomen in London in 1853,
Nightingale traveled to the Crimea in 1854 to organize sanitation and nursing for
the British army fighting the Russians there. Her career in the Crimea assumed
mythic proportions in the English-speaking world, where she was universally
revered as the “Lady with the Lamp,” caring for the soldiers, although in fact she
was more a ruthless sanitary reformer than a compassionate nurse. Her subse-
quent prestige assisted her establishment of a nursing school on the Mannheim
model at St. Thomas’s Hospital in London in 1860. She then had a long career as
an organizer and agitator for sanitary reform, both in Britain and in India; for
many years she was a self-proclaimed invalid, confined to a bed, working (and
driving her colleagues) under the pressures of imminent death, although she
lived to the age of ninety.
224 The Burdens of Disease

Much of Nightingale’s efforts centered on the health of troops, and states

seemed particularly willing to take measures in the cause of military efficiency.
The British government first moved against prostitution to protect troops from
venereal disease, and war spurred others (in addition to Nightingale) toward
nursing reform; Jean Henri Dumont’s visit to the battlefield of Solferino, in the
Austro-French War of 1859, so moved him that he organized what became (with
the support of some governments) the International Red Cross, and the same
impulse manifested itself in the work of Clara Barton in the Civil War in the
United States in the 1860s. Professional nurses, trained in the May model,
backed by the prestige of Nightingale who harnessed nursing to a devout sanita-
tionism, made hospital care of the sick a far more palatable prospect by the end
of the nineteenth century. The professionalization of nursing, together with
developments in surgery, thus reinforced the trends that medicalized disease
and isolated the sick in hospitals over which physicians presided.

The Scientific Paradigm and Medical Education

As we have seen, governments in the nineteenth century gradually
imposed a measure of uniformity on the qualifications and education of physi-
cians. Those government controls proceeded independently from the implemen-
tation of “more science” in a physician’s education, and in some cases preceded
it as well, but curricular changes and the enforcement of uniformity generally
worked together. The resultant model required would-be physicians to devote
up to four years to the study of human anatomy, physiology, pharmacology
(increasingly dominated by chemistry), and pathology as well as acquiring con-
siderable clinical experience, preferably in a hospital. While the model varied
widely, and while generalizations about the “product” are risky, a scientific para-
digm of medicine encouraged both specialization and greater impersonality. The
increasing complexity of a “scientific” understanding of the body and its func-
tions certainly led to concentration on some organs and functions, for how much
could the learner absorb? And science demanded a detached view of patients
and their diseases, one in which ailments and those who suffered from them
might be subject to experiment in order to place them properly in the system of
natural laws. The germ theory added training in microbiology to the scientific
mix and, as I shall argue shortly, enormously strengthened the appeal of the sci-
entific paradigm by its apparent success; scientific medicine truly “worked,” con-
ferring on its practitioners a powerful therapeutic advantage over their
In France the Napoleonic legislation of 1803 clearly imposed these ideals on
the national system of education and licensing. Other Western countries fol-
lowed, somewhat raggedly, in the French wake. English universities slowly
accepted a more central role for science (in their whole curricula as well as in
The Scientific View 225

medicine), although the Scottish system had done so much earlier; but both
Oxford and Cambridge remained theoretical, and their graduates had to find
clinical experience elsewhere. In the German states the spirit of Wissenschaft
began to affect the entire university system in the first half of the nineteenth cen-
tury; medical students tended to be swept up in the notion that their education
should bring them in touch with the latest research, and those with more single-
minded careerist goals were stigmatized.11 After 1869 the German medical pro-
fession depended for certification on nationwide examinations, first imposed
through legislation in the North German Confederation and then extended to
the new Empire in 1871; before the end of the century those examinations came
to assume eight semesters of medical study, including four semesters of preclin-
ical scientific knowledge. The examinations also gradually emphasized greater
medical specialization.12 American medical schools, private and basically unreg-
ulated in their early history, took on greater scientific rigor in the 1870s when
Harvard University and the University of Pennsylvania began requiring a longer
course of study, more clearly related to science and to hospital experience. The
foundation of the Johns Hopkins University medical school in 1893 carried the
scientific paradigm further into medicine by emphasizing the relation between
ongoing scientific research and medical training.13 For more and more people of
the Western world a “physician” was a person who had completed such a scien-
tific apprenticeship. Those healers who did not accept its presuppositions either
had to create a convincingly scientific alternative (as did American osteopathy,
which began in the 1870s with the healing career of Andrew Taylor Still) or be
relegated to some social margin, however substantial some margins might be.

The Persistence of Alternative Healing Modes

For many reasons, many people in the Western world remained hesitant
to take their physical troubles to orthodox physicians. Like their medieval ances-
tors, patients found that physicians might be geographically remote, socially
exclusive, or prohibitively expensive. The habits of people in traditional commu-
nities changed only very slowly; those who had always had recourse to midwives,
bonesetters, and cunning men continued to patronize them. Orthodox medicine
at the start of the nineteenth century certainly offered no clear therapeutic advan-
tage over its irregular rivals, and the acute epidemic crises of the nineteenth
century—cholera, yellow fever, typhus, diphtheria—would baffle it. And in any
case the ailments that nagged at most people were of a more chronic sort rarely
treated by physicians. The variety of respiratory troubles, dysenteries, and
tumors as well as such chronic illnesses as malaria and tuberculosis were the
special province of the village healer and the itinerant vendor of remedies.
But nineteenth-century orthodox medicine also left itself open to specific crit-
icism. Since the seventeenth century, science had raised expectations that both
226 The Burdens of Disease

made patients impatient for results and led to claims from “science” that might
have little foundation. On the heels of the germ theory came “Radam’s Microbe
Killer”; on the heels of Hiroshima came “U-235 Drinking Water.” Science seemed
to encourage certainty and some irregular treatments cheerfully promised it,
even if orthodox physicians were more cautious. In addition, the treatments
favored by orthodox physicians in the early nineteenth century were especially
daunting, involving as they did unpleasant bleeding and purging; a variety of
alternative therapies emerged that all specifically boasted of easier, gentler
Certainly the alternatives to orthodox medicine remained numerous, and they
claimed immense followings. In the United States alternative medicine enjoyed
special vigor. Orthodox medicine had little or no legal standing, and lacked the
tradition of gentility that accompanied it in the more socially stratified European
countries. Much of the American population settled some distance from cities in
a culture that encouraged self-healing techniques within families, a circumstance
in which both geographic isolation and the ideology of the independent literate
free farmer collaborated. The often-frightening remedies of orthodox American
medicine, under Rush’s influence in its most “heroic” mode, may have simply
added fuel to a situation ideally suited to the flourishing of medical alternatives.
In nineteenth-century America a rich profusion of “sects” took root, many of
which simultaneously contradicted and shared the ideas and approaches of
conventional physicians.
Samuel Thomson, a New Hampshire healer without formal education, began
his practice in the early years of the nineteenth century, and by 1813 had won a
United States patent for a system of “botanic medicine.” Thomson believed that
the maintenance of body heat was crucial to health, and that a variety of botanic
remedies could serve to maintain it. Another (perhaps obvious) Thomsonian
remedy was the steam (or hot water) bath, and Thomsonians were thus some-
times dubbed “steamers.” Thomson’s ideas gained a wide following, especially
among those Americans moving west in the second quarter of the century;
Thomsonianism had something of the character of religious revivalism, and in
fact it followed the same geographic path taken by the religious revivals spread-
ing from the “Burned-Over” district of western New York to the “West.” Paul
Starr notes that Thomson once claimed that his adherents included half the pop-
ulation of Ohio, and that even his opponents granted him one-third.14
Thomsonianism included a virulent hatred of physicians, perhaps fired by the
fact that a physician had once attempted to prosecute Thomson for murdering
a patient. That hatred of physicians also expressed a belief in the virtues of
the “common man,” who needed no fancy European educational pedigree, and
Thomsonianism may be seen as an expression of Jacksonian political culture in
The Scientific View 227

At least before about 1850 the anti-elitism to which Thomson appealed had
deep European roots as well; doctors, especially doctors supported by the pow-
ers of the state, inspired widespread resistance, fear, and even hatred. As we
have seen, the seventeenth-century Italian resistance to plague regulations found
an echo in the British opposition to measures taken against cholera in 1832.
British fear of doctors and their state-related power also stemmed from a meas-
ure that seemed, on the surface, a model of scientific enlightenment. Parliament,
responding to complaints that anatomical instruction (with its emphasis on
the actual experience of human dissection) had created the loathsome trade of
grave-robbing, passed an Anatomy Act in 1832 that permitted approved anatomi-
cal schools to acquire bodies from parish workhouses. The result was deeply
hated by the poor; previously, the only bodies legally available for dissection
were those of executed murderers, but now poverty alone could command a fate
that struck both at traditional funeral customs and at Christian belief in the phys-
ical resurrection of the body.15 For the medical profession’s relations with the
poor, the Anatomy Act’s coincidence with a cholera epidemic created a disaster,
even if it also made a more reliable supply of corpses available for medical edu-
cation. Popular fear of physicians persisted. In 1847 some Norfolk villagers
“believed that the state’s encouragement of vaccination formed a plot to kill
children under five, and Queen Victoria was a modern Herod.”16 Unwillingness
to submit to compulsory smallpox vaccination remained, throughout the cen-
tury, a point of resistance to both the powers of the state and the pride of
scientific medicine.
So while Thomsonianism was in many ways a uniquely American movement,
many of the other early nineteenth-century unorthodox therapies had European
origins. One such was homeopathy, which originated with the German physi-
cian Samuel Hahnemann (1755–1843). Hahnemann first developed his theory in
the 1790s and articulated it clearly in his Organon der Rationellen Heilkunde
(1810). Hahnemann believed that ills could be cured by very small doses of sub-
stances that—in themselves—produced the same symptoms as the disease
being treated; the phrase “like cures like” became homeopathy’s watchword.
Hahnemann married a wealthy patient late in his life, and lived in some style in
Paris. But in America especially his system gained many adherents in the years
after 1840, and before the Civil War homeopathic physicians had rapidly devel-
oped as a kind of mirror profession with the “allopaths” (as they called the
orthodox physicians). Colleges of homeopathic medicine were founded, their
memory preserved in the long-lived Hahnemann University in Philadelphia.
Unlike the Thomsonians, the homeopaths did not believe that the healing arts
lay within the grasp of the common man or woman; their medicine was complex
and sophisticated science, to be practiced by well-educated professionals. But it
was also true (as it was true of many contemporary German intellectuals) that
228 The Burdens of Disease

Hahnemann located the ultimate cause of physical phenomena in the realm of

the spirit; disease for him was fundamentally a spiritual problem.
Hahnemann’s homeopathy, while it trained its practitioners in the disciplines
of science, therefore also coincided with other more clearly “religious” alterna-
tives to orthodox medicine, some of which gained wide American followings.
Hahnemann’s ideas overlapped those of the eighteenth-century Swedish religious
philosopher Emmanuel Swedenborg, and many of Swedenborg’s nineteenth-
century American followers (whether or not they were formal members of the
New Church) also subscribed to homeopathy. In turn other Swedenborgians
were drawn to mesmerism and the other offshoots of belief in a healing “animal
magnetism,” such as hypnotism and spiritualism.
Hydropathy, another nineteenth-century medical sect, also had European
roots. Beliefs in the curative powers of water are of course very ancient and have
taken many forms, including the emphasis on bathing and “lustration” found in
Greek temple medicine and the popularity of mineral water cures throughout
Europe. Such practices assumed a somewhat different form in the ideas of the
Austrian healer Vincenz Priessnitz, who (having suffered severe accidental
injuries in his late teens) worked a self-cure with bandages of cold, wet towels.
In the 1820s Priessnitz opened a water-cure establishment at Gräfenberg, which
in subsequent decades became a mecca for health seekers. Similar facilities
began spreading in the United States in the 1840s, where hydropathy merged
with a larger and more diffuse movement that promoted “natural” health through
the reform of diet and dress. American hydropathy had particular importance for
women.17 Hydropathic theorists believed that their doctrines supported the tra-
ditional role of the woman as the caretaker of family health, for they emphasized
the maintenance of health with sensible dress, diet, and pure water. Those beliefs
also reinforced the conviction that ruggedly individual Americans could take
care of themselves without the mediation of fancy European physicians. In addi-
tion, the hydropathic doctors regarded pregnancy and parturition as normal
human conditions, not abnormal illnesses as did many orthodox physicians;
and the hydropathic medical colleges, which appeared (as did some of the
homeopathic colleges) in the years before the Civil War, enrolled women among
their students.
For many sufferers from disease the claims of medicine (whether orthodox
or irregular) were never convincing or became too overbearing. Some old reli-
gious traditions persisted or revived; newer ones arose as well. Traditional forms
of Western Christianity fought some notable battles with the new scientific para-
digms in the second half of the nineteenth century, and some of these battles
affected healing practices. In 1864 Pope Pius IX issued his encyclical Quanta
cura, which asserted that it was erroneous to believe that “[t]he Roman Pontiff
can, and ought to reconcile himself, and come to terms with progress, liberalism,
The Scientific View 229

and modern civilization”; within Roman Catholicism cults of miraculous healing

enjoyed a new popularity, perhaps most notably that at Lourdes, in France, asso-
ciated with the visions of Marie Bernarde Soubirous (St. Bernadette) in 1858.
The development of means of rapid mass transportation, particularly the rail-
road, aided the appeal of such shrines. Many Protestant groups, meanwhile, had
difficulty reconciling their beliefs with those of modern science, especially with
the theory of evolution by natural selection propounded by Charles Darwin in
1859. For at least one such group, the Seventh-Day Adventists in America, rejec-
tion of Darwin went hand in hand with an entire alternative system of health and
medicine, laid out in the writings of the sect’s leader, Ellen White (1827–1915).
Still another “antimedicine” approach emerged from Christian Science,
expounded in Mary Baker Eddy’s Science and Health, first published in 1875.
Eddy argued that disease—like sin—was an illusion, a product of the mind.
A “cure” therefore must be sought in the mind as well, and the bodily ministra-
tions of physicians (whether orthodox or irregular) were simply irrelevant.
In their appeal to women the hydropaths may have probed an especially dense
vein of those discontented with orthodox medicine. The relation of medicine and
the care of women has become a richly complex subject in modern historiogra-
phy, one in which paradoxes and ironies abound. One point of view—which has
been argued with some vigor—holds that in the nineteenth century medical
orthodoxy regarded “female” conditions as evidence of pathology; for physicians,
menstruation, pregnancy, childbirth, and menopause were all “abnormal” condi-
tions that required medical care and a doctor’s intervention. Orthodox physi-
cians thus subjected women to a variety of treatments that began as barbaric and
became (as the end of the century approached) increasingly distant, “scientific,”
“medicalized,” removed from ordinary experience, designed to place women
under a form of discipline and control. At least down to the middle of the
nineteenth century, gynecological problems were treated with such horrific
measures as cauterization or insertion of leeches into the uterus; menstrual
cramps might be solved by a hysterectomy; and by the end of the century
physicians, having gradually pushed midwives to the margin, convinced women
that babies could best be born in a hospital.
Against this aggression women responded with several different defenses.
Some evidence suggests that nineteenth-century women avoided treatment by
orthodox physicians and took their complaints instead to other healers: empir-
ics, midwives, hydropaths, medical botanists, homeopaths. The popularity of
Lydia Pinkham’s Vegetable Compound makes sense if it was an alternative to a
hysterectomy for menstrual cramps.18 In addition, as more conscious feminism
appeared by the middle of the century, some women spoke out against their
treatment at the hands of doctors and seized on the opportunities that arose to
patronize women healers. Josephine Butler, the English crusader against the
230 The Burdens of Disease

(British) Contagious Diseases Acts of the 1860s (which singled out prostitutes)
may have spoken for many other women after her visit to Elizabeth Garrett, a
woman physician:

I was able to tell her so much more than I ever could or would tell to any
man. . . . Oh, if men knew what women have to endure and how every good
women has prayed for the coming of a change. . . . How would any modest man
endure to put himself in the hands of a woman medically as women have to do
in the hands of men? . . . I pray to God that many Miss Garrett’s may arise.19

That view, that male physicians had no understanding of women’s problems,

receives some further support from the changing attitudes of doctors toward
abortion in the nineteenth century. In both Great Britain and the United States
laws forbidding abortion either appeared for the first time or became more strin-
gent, first with a British criminal statute in 1803, which was progressively tight-
ened in a series of changes down to 1861, and then with a group of laws passed
by individual American states between 1870 and 1900. Doctors in both countries
supported the new legal stringency and (especially in the United States) actively
promoted the passage of the new laws.20 In part their loyalty to the Hippocratic
oath, taken with special seriousness in the United States where professional sta-
tus was relatively weak, motivated the opposition to abortion; in part doctors
responded to new embryological views; but in part the doctors’ politics were
stimulated by the professional competition of other sects, against whom the
orthodox hoped to call down the power of the law. In France either performing
or having an abortion was a crime (as was true in Britain after 1861), although
the severity of the code of 1810 had the effect of making convictions difficult to
obtain; in Germany the imperial penal code of 1872 also sternly outlawed abor-
tion.21 For some women, the supposed unwillingness of physicians to perform
abortions or offer abortifacient advice gave them still another reason to repair to
irregular healers and the purveyors of patent medicines.
But it is not entirely clear that women were in fact the victims of doctors, or
that doctors fell out of favor with women. Gynecological problems certainly
received harsh treatment in the nineteenth century, but so did many complaints
and ailments unrelated to sex or gender. The early nineteenth century was, after
all, the age of heroic medicine; as Regina Morantz puts it, “Male genitals were
cauterized by the same complacent physicians who cauterized their female
patients.”22 Some women understandably avoided heroic orthodoxy and sought
alternatives, but so did many men. And the “medicalization” of the treatment of
women, especially in pregnancy and childbirth, was often a trend in which the
wishes of the women ran ahead of the willingness of physicians. Judith Walzer
Leavitt has argued that American women turned from midwives to male obstetri-
cians (starting in the eighteenth century) because obstetricians’ tools promised
The Scientific View 231

a relief from pain, and the same motives resurfaced when ether and chloroform
were introduced in the mid-nineteenth century. Physicians feared that these
anesthetics might be dangerous or might mask the signs of progress of labor,
but their customers demanded their use, as they did again early in the twentieth
century when the “twilight sleep” associated with scopolamine was introduced.
Leavitt makes the paradoxical point that many women supported such measures
despite the evident “loss of control” that they entailed, while many doctors resis-
ted them despite the same “gains of control” they offered.23
The arguments about abortion policy may be muddied by similar crosscur-
rents. Physicians undoubtedly became alarmed by the rise in abortions which
they perceived in the nineteenth century, and attempted to bring the practice of
abortion both under the ban of the law and under their control in those excep-
tional cases that the law allowed. But did the rise in abortions (if it occurred)
itself offer evidence of what Daniel Scott Smith has called “domestic feminism,”
the ability of women to take greater control of their private lives?24
And finally, real questions remain about chronology. Surely male fear of (and
desire to control) female sexuality was not new in the nineteenth century, and
surely doctors treated women clumsily before 1800 as well as after it. And how
thoroughly were obstetrical and gynecological events “medicalized” even by
1900? Ann Oakley notes that midwives still attended 70 percent of British births
in 1876, and that this proportion was undoubtedly even higher in rural areas.25
Only in the twentieth century did American births move to hospitals; before then,
Leavitt notes, home births remained the rule, and women, with their friends and
relations, continued to participate actively in the process.26
The ambiguities of the relations of women and orthodox medicine are
reflected in the fact that early nineteenth-century medical alternatives, and the
orthodox physicians who denounced them so roundly, actually shared substan-
tial common ground. Thomson and Priessnitz took a systemic and single-cause
view of disease, but then so too did Benjamin Rush; and while European physi-
cians such as Broussais were moving away from systemic views and toward local
ones, many of them—with Broussais a good example—remained convinced that
one grand cause produced disease. These “schools” simply disagreed about what
the grand cause was, not that it existed. They all also fundamentally believed
that medicine and health remained subjects of rational inquiry that was not
dependent on magic or divine revelation, although Hahnemann did regard health
problems as ultimately spiritual. Homeopaths and hydropaths alike aspired to
the trappings of an educated profession, founding schools of medicine to mirror
orthodoxy, while all manner of healers, whatever their links with the Jacksonian
common man, might assume the airs of a brotherhood in possession of arcane
knowledge beyond a layperson’s reach. Thomsonianism, the most self-consciously
anti-elite of these sects, itself gradually adopted more and more allopathic
232 The Burdens of Disease

remedies, transforming itself into another sect altogether under the revealing
name of “eclecticism.” As Paul Starr has convincingly argued, by the period of
(roughly) the American Civil War the sects and the orthodox were in fact, if not
yet in theory, blending together; homeopaths and eclectics were not so much
stamped out by the regulars as merged into them; as the states created their
licensing schemes in the late nineteenth century the irregulars either joined the
system or found themselves left out of the public favor that came to value the
“scientific” claims of orthodoxy.27
By the late nineteenth century the orthodox medical community had suc-
ceeded in absorbing some of the alternatives that had competed with it earlier in
the century. Its greater professional assurance, strengthened by the appearance
of some therapeutic success and by the generally rising prestige of “science,”
and ratified by its connection with university education and government licen-
sure, made it possible for it to exclude—“marginalize”—other, newer heresies
(such as chiropractic) within the realm of healing and to more clearly establish
demarcations between itself and the realm of religion.
The same theme—that of convergence of irregular and orthodox—emerged
in the world of remedies and medications. The line between homemade reme-
dies and items in an official pharmacopoeia was in any case never clear.
Physicians, apothecaries, and the vendors of remedies often (and uneasily)
inhabited the worlds of both professional healing and profitable commerce. The
eighteenth-century North Atlantic world, especially, was already an aggressively
entrepreneurial one. Advertising in newspapers, handbills, and pamphlets spread
from England to other British regions, and to northwestern Europe and North
America as well. By the nineteenth century techniques of marketing were being
perfected, with the advertising of remedies for illness taking a leading or even
pioneering role. Vendors of so-called patent medicines developed techniques
that would identify their products in the public mind: slogans, pictorial represen-
tations, trademarks, distinctive packaging such as bottle shapes, all important
because the actual products themselves might either vary little from one to
another or because the sellers insisted on the arcane character of the remedy,
which forbade them from telling the public their ingredients.
Of course the vending of remedies was hardly new. The itinerant quack was
already a stock figure in eighteenth-century Europe; Matthew Ramsey calls him
an “immediately recognizable type,” and he was clearly a well-established tradi-
tional figure when Donizetti created the character of Doctor Dulcamara in
L’Elisir d’Amore (1832).28 Nineteenth-century entrepreneurs added an enor-
mous increase in commercial volume and an enthusiastic exploitation of the
medium of print. Cheap postage, an important item on the nineteenth-century
liberal agenda, was adopted in both Britain and the United States in the 1840s;
information—and advertising—thus flowed much more freely. The growth of
The Scientific View 233

commercial patent medicine paralleled both the development of efficient postal

services and the spread of compulsory state education, which created mass liter-
acy in Western societies.
Did mass literacy mean mass gullibility? The astonishing success of some
nineteenth-century patent medicines seemed to argue that case. But the rustic
Nemorino did not need to read to be assured by Doctor Dulcamara that cheap
wine was in fact an elixir of love, and the arguments in support of nineteenth-
century medications appealed on a number of grounds. Remedies, their sellers,
and the practitioners of irregular systems of medicine all shared (and benefited
from) ambivalent attitudes toward orthodox physicians. Patent medicines
frequently advertised endorsements from physicians, and drew many of their
materials from the same pharmacopoeias to which physicians might have refer-
ence. But at the same time patent medicines set themselves apart from the “bad”
aspects of orthodox treatment. Thomas Dyott, an early nineteenth-century
American remedy manufacturer, reminded his customers that his medication
was “mercury-free,” unlike that dreadful orthodox standby calomel. Another
Philadelphia entrepreneur, William Swaim, produced medicine flavored with
pleasant wintergreen.29 Irregulars could be both “behind” and “ahead” of official
medicine. Some claimed that physicians had strayed from the path of “nature”
when they took up chemical and mineral remedies, and so they instead urged a
return to herbals and the exploitation of the science of botany. That was the
appeal of both the Thomsonians in America and the “medical botanists,” such as
John Frost, in Britain. But other irregulars gleefully seized the latest scientific
ideas, in the manner of Franz Anton Mesmer, claiming that physicians were
hopelessly conservative and unwilling to recognize the power of (for example)
electricity and magnetism. The heightened expectations of science enabled
vendors to feed on fears generated by the well-reported epidemic crises of the
nineteenth century (and the twentieth as well). Many of the patent remedies also
“tasted good” in other and more controversial ways: they contained substantial
proportions of alcohol and/or opium. The widely sold Lydia Pinkham’s Vegetable
Compound, a remedy for “female complaints,” was nearly 20 percent alcohol.30
The career of William Radam provides an instructive example of the unclear
border between vending and science. Radam, a Texas-born gardener, read about
the germ theory being enunciated by Pasteur and Koch and concluded that his
body teemed with germs. He would eradicate them the way a gardener would
kill pests, with some sweeping poison that left the plant (or himself) unharmed.
He obtained a patent for his Microbe Killer in 1886, and within a few years the
craze for microbiology had made him prosperous. He owned seventeen factories
that produced Microbe Killer, he had published a book full of photographs of
“bacteria” (hideous creatures that cried out for elimination), and he had moved
from Austin to New York’s Fifth Avenue. Attacks on his remedy by physicians,
234 The Burdens of Disease

lawsuits for libel and slander, simply gave him more publicity. Never mind that
analyses of the Microbe Killer claimed it to be over 99 percent water, to which
were added small amounts of red wine, hydrochloric acid, and sulfuric acid;
Radam flourished anyway. As James Harvey Young asks, how could ordinary
people “differentiate between the credentials of microbe-hunter Pasteur and
those of microbe-hunter Radam?”31 Analytical chemistry had become a formida-
ble science by the end of the nineteenth century, but even it might not pre-
cisely sniff out a tiny “secret” ingredient that a Radam might claim made all the
By the end of the nineteenth century “patent” medicines were being produced
by large corporations, which might deploy impressive laboratory facilities and
employ university-trained scientists. The great German chemical firms especially
illustrated that trend. With their products the line between quackery and the
pharmacopoeia became murkier still. Physicians, even with a modern scientific
education, had trouble keeping up with the pharmacological sophistication of
Friedrich Bayer’s giant works; aspirin, introduced by Bayer in 1899, was a pow-
erful remedy, an enormous source of profit, and a “patent” medicine all at once.
Such successful (and “scientific”) medication might—and often did—ensnare
physicians in a network of commercial complicity.

Germs, Diseases, and Doctors

The germ theory of disease, when taken together with the extension of
the phenomenon of vaccination to a general preventive principle, decisively
altered the relations of humans and infectious disease. It also altered, perhaps
even more decisively, patterns of etiological thought that in some ways had been
undisturbed since the triumph of Christianity in the old Roman Empire. But
those changes, while their ultimate significance is beyond doubt, did not imme-
diately sweep the nineteenth-century field, were not quickly accepted as self-
evident truth, and had only a gradual impact on disease incidence and mortality.
The professional position of physicians as healers of choice was, in the long run,
immensely strengthened by the germ theory and by vaccinations, but that result
was not a foregone conclusion in the last quarter of the nineteenth century,
despite the adulation heaped by their successors on the germ pioneers, espe-
cially Louis Pasteur and Robert Koch.
The idea that disease might be caused by microorganisms had enjoyed some
currency since the seventeenth century, when the early microscopists had first
beheld the stunning world of wee life. But at least before the 1870s such concep-
tions were usually discounted. We have seen some arguments raised against
them in connection with cholera and tuberculosis (in Chapters Seven and Eight),
arguments that reflected a more general nineteenth-century conviction that
complex interactions between people and environments best explained disease.
The Scientific View 235

By mid-century the British sanitationists and the French party of hygiene com-
manded influence, allegiance, and growing government support. For them the
germ theory was too simple; although Pettenkofer ultimately allowed that germs
might have a role, the role was in a drama with a large cast of other actors. More
generally, one of the great questions in nineteenth-century attitudes toward
nature pitted “mechanical” conceptions against “vitalist” ones, and by the middle
of the century the mechanical school predominated and vitalism inspired suspi-
cion. Mechanisms, not spontaneous life, explained organic change. “Germs” did
not necessarily mean spontaneous life, but they might imply it. They also repre-
sented an exogenous outside force perhaps affecting the entire organism, at a
time when mechanical failure might be invoked in the widely accepted etiology
that emphasized local tissue, whether in the macroscopic sense of Broussais or
in the view of cellular anatomy developed by Virchow.
Despite this prevailing environmentalist and mechanical climate the germ
theory won many converts between roughly 1870 and 1885 for a number of dif-
ferent reasons. Evidence that some diseases were related to identifiable microor-
ganisms, including fungi, had begun accumulating in the 1830s, starting with
Agostino Bassi’s studies of diseases of silkworms; in the 1840s trichinosis was
related to microorganisms found in both pork and humans, and a fungus seemed
to explain the scalp infection called favus. In the 1850s Casimir Davaine dis-
covered a microorganism in animals suffering from anthrax; “no accident,”
Ackerknecht comments, “that the first pathogenic organism discovered was one
of the largest.”32 But evidence for the causative action of such organisms
remained thin, and it required the genius of Louis Pasteur to make that evidence
convincing to the scientific and medical communities.
Pasteur, one of the dominant scientific figures of the nineteenth century, was
born in a small town in eastern France in 1822, the son of a tanner who had
served in Napoleon’s army. Pasteur carried throughout his life some of the marks
of his origins: conventionally conservative, pious, and intensely patriotic, he was
also a pugnacious controversialist with a sensitive regard for his own reputation.
But his career was marked by several uninhibited leaps, both from one disci-
pline to another and from shreds of evidence to daring assertions of certainty,
that belie a view of Pasteur as a cautious small-town conservative. He practiced
what Bruno Latour has called a “Theatre of Proof,” in which the successful out-
come of dramatic “scientific experiments” made an enormous impression on
both professional and lay mentalities.
As a young student Pasteur eventually won a place at the prestigious École
Normale in Paris, where he developed his first research specialty, crystallogra-
phy. When he completed his studies he took positions first at Strasbourg and
then at Lille, by which time (1854) his interests had shifted to the study of fer-
mentation. The prevailing mid-century view (that of the eminent German chemist
236 The Burdens of Disease

Justus Liebig) explained that phenomenon as the result of chemical and mechan-
ical changes. Sugar molecules underwent a mechanical rearrangement of their
constituents and thus changed to alcohol. But others had argued that the yeast
present in such a process consisted of one-celled organisms which directly
caused the fermentation. Pasteur took that view, and by the late 1850s had won a
European reputation by clearly showing the role of microorganisms in fermenta-
tion and putrefaction processes. Pasteur was strongly convinced that he had
shown how the “infinitely small” could play an “infinitely great” part.33 He had
also offered practical solutions to problems faced by brewers and wine makers;
to prevent products from spoilage as a result of overfermentation, the makers
simply had to kill microorganisms at the right point, perhaps by heating (or
Pasteur’s success, as the man who showed the workings of microorganisms
in fermentation, inspired others to extend the idea that “bacteria,” everywhere
present as Pasteur argued, had other effects, including perhaps disease. One
such convert, the British surgeon Joseph Lister (1827–1912), believed that such
germs might be responsible for the “sepsis,” or infection, that followed wounds
and surgical openings. In 1864 he began experimenting with different techniques
of “antisepsis” in surgery, and while certain success only developed after a trial-
and-error process, Lister’s antiseptic methods ultimately ranked with anesthesia
in changing both the safety of, and opinions about, surgery. But Pasteur, while
generally convinced of the importance of bacteria, was after all a professor of
chemistry, not a medical practitioner; by the mid-1860s he had become interested
in the silkworm diseases to which Bassi had earlier called attention, and his focus
remained on those, as well as on beer and fermentation, until the mid-1870s.
Pasteur’s work undoubtedly strengthened the hand of those medical
researchers who believed that germs might cause disease. Among them was
Robert Koch (1843–1910), the son of a German mining official, who received a
medical degree from the University of Göttingen in 1866. One of his teachers
there, Jacob Henle, himself espoused the germ theory. Koch practiced medicine
in small German towns (first in Hannover, then in Posen) and it was from that
rural obscurity that he produced (in 1876) an impressive study of the life cycle
of the organism responsible for anthrax. Davaine (and others) had earlier associ-
ated a microorganism with that animal disease; Koch isolated the organism from
sick animals, grew laboratory cultures of it, and then used those cultures to infect
healthy animals with what developed as anthrax. The excited Pasteur, shifting to
the study of infectious disease, confirmed Koch’s findings (incidentally starting
a quarrel over priority), and began extending his reach to other diseases of
animals: chicken cholera, swine erysipelas, and rabies.
In the course of his investigations Pasteur learned that some animals could
carry massively reproducing colonies of chicken cholera bacteria without
The Scientific View 237

themselves showing symptoms of the disease. He also discovered—almost by

accident—that some cultures of bacteria lose their lethal character for some rea-
son, becoming “attenuated,” and may remain so through subsequent genera-
tions. These points recalled human experience with smallpox inoculation and
vaccination to Pasteur’s mind. In those cases some form of attenuated disease
“essence” had been engrafted that prevented the serious symptoms of smallpox
from appearing in the subject. Could not the same be done with attenuated
“essence”—bacteria—of chicken cholera? If so, “vaccines” for diseases caused
by microorganisms might be produced at will, provided that a reliable method of
attenuation could be developed. A variety of experiments performed in Pasteur’s
laboratory (he had returned to the École Normale in Paris in 1857) suggested
different methods of attenuating microorganisms: age them, warm them, pass
them through a succession of animals.
Pasteur staged his first great “Theatre of Proof” in 1881. Anthrax, the disease
that had been early associated with a microorganism and then convincingly
shown so by Koch, was also a killer whose depredations of sheep and cattle gave
it economic importance. In March 1881, when Pasteur announced that he had
produced a workable vaccine for anthrax, French (and other) agricultural inter-
ests responded. The Agricultural Society of Melun, under the prodding of Henri
Rossignol, a veterinarian skeptical of the germ theory, proposed a test, and
Pasteur agreed to its terms. A group of animals at Pouilly-le-Fort (eventually
twenty-four sheep, six cows, and a goat) would be “vaccinated” against anthrax
by Pasteur. Subsequently they would receive a fully lethal dose of the anthrax
organism, as would a comparable control group of animals that had not been
vaccinated. Two days after this second treatment, on June 2, before an excited
crowd that included representatives of the international press, all the vaccinated
animals were alive (although one died shortly afterward), while all the unvacci-
nated were either already dead or dying of anthrax; two sheep cooperatively
expired while the assembly watched. The sensation was immense. “Pouilly-
le-Fort, as famous today as all the battlefields,” wrote Henri Bouley in 1883.34
Pasteur had taken a gigantic chance and been justified by the results.
Meanwhile claims had been made for the isolation of the agents of some
human diseases. Discoverers had more trouble verifying these claims, for they
hesitated to follow all of the steps modeled by Koch’s anthrax experiments, espe-
cially the infection of healthy animals (in this case humans) with bacteria culti-
vated in the laboratory. That understandable difficulty limited the acceptance of
the “discovery” of the causative organisms of leprosy (by Gerhard Hansen in
1868), of gonorrhea (by Albert Neissner in 1879), and of typhoid fever (by Carl
Eberth in 1880). Although Koch was not in Pasteur’s class as a showman, he pro-
vided his own sensation in 1882 when he announced the discovery of
Mycobacterium tuberculosis; Paul Ehrlich, who was present, recalled that the
238 The Burdens of Disease

“audience was too spellbound to applaud or engage in official discussion.”35 In

fact in the 1880s the paths of Koch and Pasteur diverged. Koch and his followers
embarked on the isolation and identification of causative microbes, in increas-
ingly well equipped laboratories supplied by the German state and university
system. Koch, no longer an obscure country practitioner, had become an advisor
to the Imperial Public Health Department in Berlin (in 1880) and a professor at
the University of Berlin (in 1885). Pasteur meanwhile focused on the develop-
ment of vaccines, and a vaccine for a human disease afforded him an even more
spectacular “Theatre of Proof.”
His target—rabies—was a disease with particularly powerful cultural associa-
tions. In the nineteenth century rabies affected relatively few people in the
Western world; its victims numbered fewer than one hundred per year in both
France and Britain, for instance. But it inspired peculiar horror. A disproportion-
ate number of its victims may have been children, bitten by those most domesti-
cated friends of humanity, dogs. The latency of the disease meant that once
bitten by an animal a person endured a month of terrible suspense, wondering
whether rabies would strike. And if it developed that the biting animal had been
rabid, and the disease took hold in the victim, both horrific symptoms and cer-
tain death ensued. The symptoms associated the disease with both bestiality and
sexuality; victims raged and attempted to bite others, and they seemed in a con-
stant state of priapic sexual arousal. Kathleen Kete has convincingly argued that
the combination of violence and sex brought together the most “dreadful topics”
for the nineteenth-century bourgeoisie, and gave rabies its particular cultural
significance. People in different times and places created different social con-
structions of the disease. At least for a time among the middle classes of both
France and Britain, rabies seemed a disease originating in the undisciplined dogs
of the undisciplined lower orders. But in the years after 1850 French opinion
tended to lay the responsibility for rabies on the refinements of urban civiliza-
tion, which created an unnatural life (especially one that denied sexual outlets)
for the domesticated pets of the city bourgeoisie.36 Did rabies develop sponta-
neously in such frustrated canines? If so, might rabies be a judgment on the over-
refinements of civilization?
Meanwhile in Britain the growing popularity of domestic dogs contributed to
a debate about the ways in which the state might control them and hence per-
haps control the spread of rabies. A British parliamentary act of 1871 gave local
authorities power to muzzle dogs, but arguments about the effects of doing so
went on into the 1890s.37 Similar controversy raged in France, where a Paris city
ordinance had compelled the muzzling of dogs as early as 1845, but there—as in
Britain later—enforcement was sporadic. In addition to the urgings of those who
felt muzzles represented cruelty to animals, both class and etiological opinions
intruded; the urban middle classes might say that their little lap dogs never came
The Scientific View 239

into contact with the ravening brutes of the poor, so why should they be muz-
zled, while those who believed in “spontaneous rabies” feared that muzzles might
simply build up frustrations in the dog and hence make it more dangerous.
Pasteur began experiments on rabies in the early 1880s, hoping to find a
causative organism and attenuate it for a vaccine. Finding the organism proved
difficult, for rabies is in fact a viral disease whose organism is too small to have
been detected by nineteenth-century microscopes. But Pasteur and his associ-
ates worked on “vaccines” anyway, using fluids extracted from the tissues of
infected animals, assuming such fluids carried the hypothetical causative organ-
ism. (After all, Jenner had never seen the smallpox organism, and Koch and his
microbiologists hadn’t seen it either.) In that way trial vaccines were prepared,
and experiments testing their efficacy on animals begun. The long period of
latency (between bite and symptoms) made Pasteur believe that the vaccine
might still be effective after exposure. Then in 1885 the opportunity for theatre
presented itself, or was seized. Joseph Meister, a nine-year-old from Alsace, was
brought to Pasteur by his frantic parents; he had been bitten by a dog, and rabies
loomed. Pasteur (or more properly a physician allied with him, for Pasteur could
not treat humans without fear of legal repercussions) administered a series of
inoculations of the attenuated vaccine to the boy, who survived unscathed. From
that point Pasteur’s position as a benefactor of the human race was assured. By
November 1886 Pasteur’s Paris laboratory had treated 2,500 people with rabies
vaccine.38 In the 1960s a poll asked a group of French schoolchildren to name
who had done the most good for the country. Pasteur was named by 48 percent,
far ahead of all others, including St. Louis (20 percent) and the then-living
President de Gaulle (9 percent).39
But the panegyrics lavished on Pasteur, then and since, should not obscure
the uncertainties that surrounded both the rabies vaccine and the more general
“germ” theory that it seemingly vindicated. Personal difficulties divided the camp
of the microbe hunters; Pasteur and Koch had serious scientific differences and
quarreled over priority and the effectiveness of techniques, while national rival-
ries, felt by both men, exacerbated their relations. Pasteur, after all, had returned
the University of Bonn’s honorary degree when the Franco-Prussian War started
in 1870; according to an American visitor, in 1886 Pasteur said: “The Germans
are angry, especially Koch, because France has the merit of this new discovery
of protection against rabies. They think that because they conquered our coun-
try in ’70 that they can be our masters in this field and therefore they spread
broadcast their skepticism against me.”40 As Gerald Geison has shown, tensions
also existed within Pasteur’s own laboratory, where his chief assistant, Emile
Roux, had serious doubts about some of the master’s decisions. The vaccine
used in the great anthrax demonstration was not what Pasteur led the public to
believe it was. More serious yet, the Meister rabies test was even riskier than it
240 The Burdens of Disease

seemed, for Pasteur’s animal experiments had not advanced nearly as far as he
hinted they had, and the method of vaccination that he used on Meister had
not been tried on an animal at all. Those critics (whether inside the camp of
microbiology or outside it) who attacked Pasteur’s risk taking were on even
firmer ground than they realized.41
The effectiveness or epidemiological importance of Pasteur’s rabies vaccine
also came into question. Were the 2,500 people vaccinated in 1886 really saved
from rabies, when fewer than 100 in France ordinarily died of rabies every
year? Pasteur argued that the morbidity and mortality statistics of rabies
seriously under-reported its true extent, but was mass inoculation of everyone
bitten by an animal the best way to attack rabies? Was it possible that laboratory-
generated strains of the disease might result in more cases rather than fewer?
Was the vigorous policing and muzzling of dogs—what might be called the gen-
eral public health approach—a surer route to the elimination of the scourge than
the microbiological? The success of Great Britain in eliminating rabies from
its territory by the second decade of the twentieth century by careful policing
and quarantine argued that microbiology and vaccines were hardly needed.
And as we have seen with both tuberculosis and cholera, the “discovery” of
a causative organism did not result in any immediate breakthrough in the
prevention and treatment of either; a vaccine for tuberculosis emerged only
slowly, incompletely, and surrounded by controversy, and Koch’s attempts to
impose his bacteriological model on Hamburg during the 1892 cholera epidemic
were widely resisted.
But germ theory and the possibility of preventive vaccination commanded
enormous respect regardless. Pasteur’s daring experiments had worked: twenty-
four Melun sheep lived, Joseph Meister lived, and the world’s press reported it
all. Bruno Latour, in a sensitive discussion of the grounds for acceptance of the
germ theory, suggests that Pasteur’s theatre won converts partly because it was
theatre, but also because germ theory provided the dominant “hygiene” or
“sanitationist” approach with a crucial tool. Sanitationism or “hygiene” took
a very broad view of disease etiology, unwilling to rule out any conceivable vari-
able. But as Latour says, “[s]ince anything might cause illness, it was necessary
to act upon everything at once, but to act everywhere is to act nowhere.” Students
of public health, the party of hygiene, seized upon Pasteur and germ theory
because with them the attack on disease gained sudden and dramatic focus.
All the problems that consumed the sanitationists—“overcrowding, quarantine,
smells, refuse, dirt”—could be “retranslated or dissipated. Either the microbe
gets through and all precautions are useless, or hygienists can stop it getting
through and all other precautions are superfluous.” 42 Some dramatic attacks on
microbes were made in subsequent decades by sanitationists, attacks that vindi-
cated germ theory more clearly than did controversial vaccines; but the success
The Scientific View 241

of Pasteur’s theatrical vaccine trials had given the sanitationists a direction that
they had lacked.
Germ theory established the “objective,” “external” view of disease more
firmly than ever. Disease had an independent existence, apart from the healthy
animal or human frame. Latour notes that anthrax quickly went from being a
“cattle disease” to a “disease of the anthrax bacillus,” and that model was to be
followed for many others.43 When Florence Nightingale, a sanitationist who did
not like the germ theory, insisted that disease was “an adjective, not a noun sub-
stantive,” she spoke for an earlier tradition, one that placed “disease” and
“health” on a continuum; the body was more or less healthy or diseased, never
wholly one or the other except in death. Germs located diseases in their own
separate organisms, which invaded an otherwise-healthy body. Germ theory also
stood as a logical extreme in trends in nosology, which had—since the
eighteenth or even the seventeenth century—been moving slowly and fitfully
toward more distinct definitions of separate diseases, understanding that small-
pox differed from measles in more than just degree. Germ theory explained
those distinctions as the product of different microorganisms.44

Concluding Thoughts
By the end of the nineteenth century science had reshaped attitudes
toward disease in several ways, not always in agreement with one another.
Beyond doubt disease could be conquered, as an external enemy. Several differ-
ent groups of warriors claimed the central place in the battle line: engineers, if
one accepted the preventive powers of sanitation; microbiologists, if one saw
germs as the great foe. And in any case, microbiology had also suggested new
possibilities of cure as well as prevention. If causative microorganisms could be
killed after they invaded the body, or if their actions could in some manner be
neutralized, then the physicians who mastered those techniques would stand as
undoubted healing geniuses. Of course the healers might not be physicians.
Pasteur, a chemist, “cured” rabies; Radam, an entrepreneur, claimed to cure
many things. But this therapeutic promise came at a time when physicians in the
West had clearly associated themselves with “science,” and they had also won
increasingly strong legal positions of professional privilege, reflecting the pres-
tige of science and the hopes that it inspired.
And the changing character of Western civilization in the nineteenth century
also strengthened the hand of the scientific physician. To the extent that the
Western world became more urban, it probably lost touch with much traditional
healing and with many traditional healers. In part for the same reason, an increas-
ing proportion of the Western population fell out of touch with the everyday pres-
ence and pressure of religion. The oft-cited British census of 1851, which
included inquiries about religious observance showing that less than half of the
242 The Burdens of Disease

population attended Christian services on a given Sunday, stood as evidence

of the decline in religious practice. (The same census also showed that more
than half the British population could be defined as urban.) In place of religion
and traditional healing would come new forces, many of them commercial, still
others professional, which would create and reflect both wants and expectations.
Some of those expectations related to the conquest of disease, and physicians—
and the vendors of medications—promised that conquest. But did the new
science win its war? Did germ theory, combined with sanitation, mean an “End
of Epidemics”?

The Apparent End

of Epidemics

B y the middle of the twentieth century some social and medical

observers (including historians) believed that the end of epidemic diseases was
in sight. The American magazine U.S. News and World Report, reflecting in 1955
on the development of a poliomyelitis vaccine, maintained, “There are diseases
that offer threats, but, over all, in the field of infectious ones, most of the killing
ones are under control.” The same magazine confidently predicted that “[m]an
one day may be armed with vaccine shields against every infectious ill that besets
him.” Richard Harrison Shryock, a distinguished historian of medicine, allowed
that Condorcet’s remarkable Enlightenment prediction that science would free
humanity of old age and death “may yet prove correct.”1 Scientific biomedicine
had combined with sanitary engineering, sophisticated political machinery, and
widespread public enthusiasm for the dictates of health to bring to apparent
fruition the promises of science first made in the seventeenth century. One by
one the perils of various infectious epidemic diseases seemed to fade away under
the combined assault of enlightened public health and sanitation, the extension
of the preventive principle of vaccination, and the curative powers of laboratory
products, among which antibiotics created the greatest sensation and held out
the most exciting prospects. In many ways twentieth-century scientific medicine
changed the relations between humans and disease both decisively and for the
better. Although scientific medicine owed most of its earlier success to nonmed-
ical factors, a review of recent Western population history will show its demo-
graphic significance in the years after World War I.
Two other phenomena have, however, intruded on that progressive picture:
scientific medicine succeeded only by fits and starts, and never completely; and
some of its consequences were both unforeseen and unpleasant. Disease,

244 The Burdens of Disease

considered as an objective and biological reality, continues its symbiotic rela-

tions with its human hosts despite biomedicine’s best efforts; considered as a
human mental construct, twentieth-century disease wears many faces, some of
them molded by the purported end of epidemics, but others with a different,
sometimes long (and not often happy) history.

Disease, Medicine, and Demography

The balance of power between people and certain infectious diseases
shifted decisively (although perhaps temporarily) in the first sixty years of the
twentieth century. Mortality from tuberculosis, syphilis, bacterial pneumonia,
diphtheria, whooping cough, measles, and poliomyelitis (among others) plunged
dramatically, in each case as a direct result of the application of preventive or
curative biomedicine. But the demographic significance of those successes is
harder to assess, for they followed on the heels of other demographic change
mediated by human (not necessarily medical) agency.
Were human responses to disease demographically effective even before the
twentieth century? That question has been among the most widely discussed
issues in modern historiography, and its resolution remains elusive, both
because of the very large number of variables determining mortality (many of
them interrelated if not actually interdependent) and because basic data for the
period before the middle of the nineteenth century are fragmentary at best. Some
review of the variables, and of the present tentative conclusions of scholarship,
may place the impact of triumphant biomedicine in a clearer context.2
Modern demographic historians now widely agree that the transition to
today’s low mortality in the West occurred in two or perhaps three stages. The
first stage, roughly the eighteenth century (or perhaps the period from about
1730 to about 1820), saw a decline in mortality rates. Although that decline was
halted in the early and mid-nineteenth century, it was not succeeded by notable
upward surges in mortality rates of the kind that had marked the cyclical move-
ments of earlier Western population history. Instead, after a mid-nineteenth-
century pause, the decline in mortality resumed with perhaps greater force in
the last thirty years of the century, and that decline, though staggered by the
appalling experience of early twentieth-century wars and an influenza pandemic,
became steeper by the mid-twentieth century, a period that may constitute a third
and separate stage.
Of these periods the first is at once the simplest and the most difficult: simple
because the number of variables may be fewer, especially those of human
agency; difficult because the data are both sparse and controversial. This book
has already noticed some of its likely elements, one of the most important of
which was the decline in “crisis mortality” that followed the disappearance of
plague from the West. The role of human agency in plague’s remission remains
The Apparent End of Epidemics 245

dubious (see Chapter Three), although a case has been made for the efficacy of
quarantines in checking plague’s diffusion. More serious doubts surround the
purported decline of other diseases that may have contributed to “crisis mortal-
ity,” especially smallpox. If the mortality from smallpox declined (an unproven
point), was eighteenth-century inoculation both widespread enough and effec-
tive enough to have had a demographic impact? Or might the lethality of small-
pox have declined autonomously?
Of course human agency may have been more general and less direct than a
straightforward attack on specific diseases. Thomas McKeown, whose ideas on
the cause of declining mortality have become both a paradigm and a target,
argued that improvements in nutrition should receive credit for most of the
reduction in Western mortalities before the twentieth century.3 Applying
McKeown’s thesis to the eighteenth century has been frustrated by a lack of
data, especially about causes of death. The lethality of plague and smallpox has
little or nothing to do with victims’ nutritional state, and until we know more pre-
cisely what killed eighteenth-century Europeans, “nutrition” will remain a specu-
lative explanation. It is true that new high-calorie crops (notably the potato)
spread in some parts of Europe. It is also true that in some places a more
“national” grain market developed, which may have reduced local shortages and
famines, and that the stronger governments of the Enlightenment made efforts
to counter subsistence crises.
More important, however, may have been measures stimulated by
Enlightenment ideologies, undertaken by a combination of government and the
general public. As James Riley has argued, a belief in the importance of “envi-
ronment” pervaded the Enlightenment, and led governments and private individ-
uals to undertake environmental changes such as drainage and urban cleansing
as part of attacks on general “miasmas.”4 The often-inadvertent result may have
interrupted the lives of disease vectors, especially insects. Yet more convincing
is the suggestion of Marie-France Morel that Enlightenment ideology began an
important change in the care of infants, which in turn led to a reduction in infant
mortality (at least in France) by the late eighteenth century.5 Morel notes the
Enlightenment view of infancy as a time of uncorrupted goodness, which joined
increasing state concerns with ensuring population growth and hence state
power. By the time of the revolution French mothers were urged to breast-feed
their children, the practices of unskilled midwives were under attack (as were
wet-nurses), and leaders of medical and social opinion demanded new levels of
hygiene. Of course these measures could only spread through the population
slowly, despite any number of government orders; but Morel’s data certainly
show a decline in French infant mortality after about 1790.
So improved nutrition, attacks on general environmental “corruption,”
changes in the care of infants, and the beginnings of preventive measures against
246 The Burdens of Disease

smallpox may all have been human-mediated causes of declining mortality rates
by the end of the eighteenth century. But the most important clue was the dog
that didn’t bark—plague—and the human role there remains unproved. Alfred
Perrenoud makes the stimulating suggestion that our view of the role of climate
may have been misplaced, focusing as it has on the relation between climate and
crops. The eighteenth century was the heart of the “Little Ice Age” in the West,
and Perrenoud argues that it may have therefore been a difficult age for disease-
bearing microorganisms and their vectors.6
By the early decades of the nineteenth century the disease environment had
changed, as we have seen in Chapters Seven and Eight. The great crisis epi-
demics, especially plague, had receded, although assertions that they had
entirely disappeared depend too much on evidence from a few well-studied north-
western European countries. The new importance of more endemic infections,
however, especially those that flourished in the urban conditions of the
nineteenth century, offset the gains made against crisis epidemics. Airborne dis-
eases of crowds, especially tuberculosis but also diphtheria, measles, and
influenza, had greater opportunity, as did waterborne diarrhea, dysentery,
cholera, and typhoid. The likely decline in living standards for many urban
dwellers, at least in some period of the century, brought together an array of
interconnected variables: poorer nutrition, crowded housing, lack of clean water
and sewage removal, and exposure to hazardous work environments that may
also have included carcinogens. Infants and children may have been particularly
at risk from diseases carried by contaminated foods and impure water. For what-
ever combination of reasons, the declines in infant mortality seen earlier in
France and England came to a halt by the middle of the century.
That mid-century check proved temporary, for strong evidence exists that a
decline in mortality resumed in the last decades of the nineteenth century (see
Table 11.1). To explain that decline requires a truly multicausal analysis. The
greatest contributions to the declines came from reductions in infant and child
mortality and from falling death rates from tuberculosis. Both those subjects
involved a variety of autonomous, social and economic, public health, nutritional
and deliberate medical causes, and so well illustrate the complexities of explain-
ing demographic change and its relation to disease.
Infant and child mortality fell partly because the gradual adoption of different
child-rearing practices noticed by Morel in the late eighteenth century gained
momentum in the late nineteenth. Concerns with national health generated by
political fears of national “degeneracy,” common, for example, in France after 1871
and Britain after 1899, manifested themselves in many ways, but they included
national intervention in infant and child welfare, inspection of premises by public
health nurses, and instruction for and propaganda directed to mothers on the
benefits of breast-feeding, timely inoculations, frequent baths, hand washing
The Apparent End of Epidemics 247

Table 11.1
Death Rates in Selected Countries: Nineteenth Century and c. 1914

Crude deaths/1,000 population

Country 19th century By about 1914

Austria Over 26 every year until 1897 20.3 in 1913

England/Wales Over 20 every year until 1881 13.3 in 1912
France Over 20 every year until 1897 17.5 in 1912
Germany Over 23 every year until 1894 15.0 in 1913
Italy Over 25 every year until 1895 17.9 in 1914
Russia Over 32 every year until 1897 26.5 in 1912
Spain Over 26 every year until 1903 21.3 in 1912

Source: Compiled from B. R. Mitchell, European Historical Statistics, 1750–1970 (New York:
Columbia University Press, 1975), 105–119.

before food preparation, and the boiling of water and milk. As Morel admits, the
spread of such practices could not be dramatically imposed from above, but surely
they had an impact.7 Those conscious attempts to improve infant and child wel-
fare, regardless of their motivations in the gritty realities of nationalist power,
combined with the improving home environments that characterized maturing
industrial economies. The size of houses increased, reliable piped water supplies
and sewage removal systems reached them, and technological changes made
household surfaces easier to clean.8
The incidence and/or mortality of specific childhood diseases began falling in
the decades after 1870 for a variety of reasons. Diphtheria, a serious childhood
scourge by the mid-nineteenth century, retreated partly as a result of reducing
crowding in urban housing, thus decreasing the opportunities for airborne trans-
mission. The beginnings of surgical treatment—tracheostomy—may have con-
tributed to a reduction in mortality. But as Anne Hardy notices, the severity of
the disease was coincidentally declining autonomously. Hardy also notes that the
fall in scarlet fever mortality ran ahead of morbidity decline, suggesting another
exogenous decline in severity, although that disease may also have earlier flour-
ished in crowded conditions where the possibility of larger infective doses
existed.9 Whooping cough’s decline may have been related to improved nutrition
and also to the gradually improving child nursing habits mentioned by Morel.
And although mortality from measles declined more slowly before World War I—
its morbidity was kept especially high by the spread of compulsory education in
Western states—it too responded to improvements in nutrition, housing, and
parental nursing habits. These reductions in childhood infectious disease
occurred at different rates in different places. Graziella Caselli’s comparative
248 The Burdens of Disease

study of England and Italy suggests that by the middle of the nineteenth century
England had already achieved some such reduction (as apparently had
France), perhaps owing to greater social and economic change, perhaps to
Enlightenment-inspired changes in parental customs.10 Italian rates (and perhaps
also German) remained higher until the late nineteenth century, but they then
fell dramatically in the face of rapid economic change and state pressure for
healthier children.
The case of tuberculosis was especially important for late nineteenth-century
mortality, and its complexities have already been discussed (see Chapter Eight).
Its severity may have declined autonomously, or Westerners may have gained
more resistance to tuberculosis through a grim process of natural selection by
the end of the nineteenth century. Improvements in nutrition, if and when they
occurred, certainly strengthened the ability of individuals to resist the serious
manifestations of a tuberculosis infection. A whole range of “standard of living”
improvements in the late nineteenth century may have been relevant, especially
reductions in overcrowded dwellings and the provision of fresh air access in
workplaces and schools. Reduced residential density, related both to rising per
capita incomes and to the developing technology of commuter transportation,
generally lessened the likelihood of airborne infection. The isolation of victims in
sanatoria, hospitals, and workhouses reduced the chances of contagion. Again,
rates varied from place to place (see Chapter Eight), with more dramatic reduc-
tions in the areas of greatest economic development. In some cases, but not all,
high initial rates also accompanied proportions of urban concentration;
England’s tuberculosis rate, considerably above Italy’s in 1871, fell to approxi-
mate the latter’s by l901.11
While tuberculosis and childhood infections receded due to a variety of
human responses and exogenous changes, the water- or foodborne diseases—
cholera, typhoid, diarrhea, dysentery—clearly fell to improved sanitary regi-
mens, including water purification, sewage and refuse removal, and changes in
food preparation and personal habits. Regional differences in those diseases
remained striking through World War I, depending clearly on the impact of the
sanitary gospel. Death rates from diarrhea and enteritis in Italy were three or
four times their English equivalents in 1881, and actually increased in the next
twenty years. By the end of the century typhus was largely eradicated from coun-
tries such as the United States and Britain where sanitation had entered the
national ethos (although the disease’s specific etiology remained a mystery); in
other places it persisted and enjoyed a powerful revival in the filthy (and often
lousy) horror of World War I.
Thus while curative medical intervention played almost no demographic role
in the late nineteenth and early twentieth centuries, it does not follow that demo-
graphic decline occurred solely for inadvertent or exogenous reasons. Deliberate
The Apparent End of Epidemics 249

preventive actions—those of sanitation, urban and workplace regulation, hous-

ing codes, infant health propaganda—played an important role, joining other
more consciously medical preventives such as smallpox vaccination and the
growing insistence on antiseptic conditions, the last-named probably important
in declining infant (and maternal) mortality. And perhaps most important of all
for health, many fully industrial societies achieved a dramatic decline in birth
rates. Smaller families had many benefits for the health of their members, includ-
ing (but not limited